Long term safety and effectiveness of LVIS Jr for treatment of intracranial aneurysms- a Canadian Multicenter registry.

BACKGROUND: The Low-profile Visible Intraluminal Support device (LVIS Jr) has become a commonly used intracranial stent for the treatment of intracranial aneurysms. However long-term stability and effectiveness remains to be seen. The purpose of the study was to assess the long-term efficacy, safety and durability of LVIS Jr. in a retrospective multicenter registry. METHODS: Patients with saccular aneurysms treated at centers across Canada using LVIS Jr for intracranial aneurysms were included in this retrospective registry between the dates of January 2013 and April 2019. Self reported outcomes were collected and used to assess both perioperative and long term safety and effectiveness. Both univariate and multivariate analysis were performed. RESULTS: Total of 196 patients (132 Women; mean age of 57.6 years) underwent endovascular aneurysm treatment with at least 1 LVIS Jr. stent. Mean aneurysm dome size was 7.4 mm, and mean neck size of 4.3 mm. Mean clinical and imaging follow up were 950 and 899 days respectively. Class I/II was achieved in 85% on long term follow up. Periprocedural morbidity and mortality was 4.6% and 2% and additional delayed morbidity and mortality was 3% and 2.5%. Aneurysm size >10 mm was independent predictor of periprocedural complication (OR 2.59, p = 0.048) while an increased dome to neck ratio >1.5 was independent predictor of increased delayed complications (OR 3.99, p = 0.02). CONCLUSION: The LVIS Jr. intracranial stent is an effective device in the treatment of intracranial aneurysms. Satisfactory long term occlusion rates can be achieved safely with stent-assisted coil embolization.

Vasospasm following low-velocity penetrating pediatric intracranial trauma.

BACKGROUND: BB guns or non-powder guns created in the modern era are able to reach exceedingly fast velocities as a result of advances in compressed-gas technology. While missile penetrating trauma has been well documented in neurosurgical literature, penetrating intracranial injury secondary to non-powder guns, along with their associated complications and treatments, is not well described, and even less so in the pediatric population. CASE PRESENTATION: Here, we describe an unusual case of a 6-year-old Indigenous child who was accidentally shot with a BB gun to the head. He subsequently developed delayed acute right-sided weakness due to symptomatic vasospasm. His symptoms resolved following hypertensive therapy, balloon angioplasty intervention, and intra-arterial milrinone therapy. CONCLUSIONS: This case highlights the unique complication of delayed symptomatic vasospasm in a child following a non-missile intracranial penetrating injury. Intracranial vasospasm needs to be considered in the presence of delayed neurological deficit given its potential reversibility. This case also emphasizes the importance of gun safety and education when handling and storing these potential weapons around children.

Effectiveness and safety of endovascular thrombectomy for large versus medium vessel occlusions: a single-center experience.

BACKGROUND: The effectiveness and safety of endovascular thrombectomy (EVT) for medium vessel occlusions (MeVO) in the anterior intracranial circulation for patients with acute ischemic stroke (AIS) has yet to be definitively established. We compared outcomes in patients undergoing EVT for large vessel occlusion (LVO) versus those with MeVO. METHODS: This retrospective cohort study, using an intention to treat design, compared the 90-day modified Rankin Scale (mRS) score between 43 patients with MeVO and 199 with LVO in the anterior intracranial circulation. Secondary outcome measures included vessel recanalization using the Thrombolysis in Cerebral Infarction (TICI) score, procedural complications, post-EVT intracranial hemorrhage (ICH), and infarct size. RESULTS: The rate of good functional outcome (90-day mRS 0-2) was higher in patients with LVO than in those with MeVO (32.9% vs 27%), but this was not statistically significant (p=0.19). The rate of EVT procedural complications was also not significantly different between the groups (p=0.10), nor was the rate of ICH (p=0.30). There was also no significant difference in TICI scores between groups (p=0.12). Infarct size was larger in the LVO group (p<0.01). Multivariate analysis showed older age, not receiving recombinant tissue plasminogen activator (r-tPA), and larger infarct size were independent predictors of poor functional outcome at 90 days. CONCLUSION: The 90-day mRS and rate of periprocedural complications were not significantly different between patients treated for LVO and those treated for MeVO with EVT. Older age, not receiving r-tPA, and larger infarct size were independent predictors of poor outcome at 90 days.

Access to Endovascular Thrombectomy for Stroke in Rural Versus Urban Regions.

PURPOSE: Endovascular thrombectomy (EVT) significantly improves outcomes for acute ischemic stroke patients with large vessel occlusion (LVO) who present in a time sensitive manner. Prolonged EVT access times may reduce benefits for eligible patients. We evaluated the efficiency of EVT services including EVT rates, onset-to-CTA time and onset-to-groin puncture time in our province. MATERIALS AND METHODS: Three areas were defined: zone I- urban region, zone II-areas within 1 h drive distance from the Comprehensive Stroke Center (CSC); and zone III-areas more than 1hr drive distance from the CSC. In this retrospective cohort study, EVT rate, onset-to-groin puncture time and onset-to-CTA time were compared among the three groups using Krustal-Wallis and Wilcoxon tests. RESULTS: The EVT rate per 100,000 inhabitants for urban zone I was 8.6 as compared to 5.1 in zone II, and 7.5 in zone III. Compared to zone I (114 min; 95% CI (96, 132); n = 128), mean onset-to-CTA time was 19 min longer in zone II (133 min; 95% CI (77, 189); n = 23; p = 0.0459) and 103 min longer in zone III (217 min, 95% CI (162, 272); n = 44; p < 0.0001). Compared to zone I (209 min, 95% CI (181, 238)), mean onset-to-groin puncture time was 22 min longer in zone II (231 min, 95% CI (174, 288); p = 0.046) but 163 min longer in zone III (372 min, 95% CI (312, 432); p < 0.0001). CONCLUSION: EVT access in rural areas is considerably reduced with significantly longer onset-to-groin puncture times and onset-to-CTA times when compared to our urban area. This may help in modifying the patient transfer policy for EVT referral.

Suboptimal Outcome with Endovascular Thrombectomy: Will Acute Stroke Unit Help?

Endovascular thrombectomy (EVT) has revolutionized the care of patients with acute ischemic stroke. The efficacy of EVT is dependent on the optimal setup of a stroke system. Extrapolating the results of clinical trials to any individual stroke center should be done with caution. This is more important for centers with suboptimal stroke systems of care. The Canadian registry has helped highlight the suboptimal outcome post EVT in Manitoba. This could potentially be optimized with the addition of an acute stroke unit in the near future. Our study will serve as a baseline for future improvement in acute stroke care.

West Nile Virus infection in a renal transplant recipient resulting in polioencephalomylelitis, quadriplegia, and global brain atrophy.

An immunosuppressed man developed rapidly progressive neurologic symptoms resulting in quadriplegia. On magnetic resonance imaging multiple areas of abnormal enhancement were observed in the brain, and spinal cord. Serologic evidence of West Nile Virus (WNV) was discovered in the cerebrospinal fluid. This report highlights the catastrophic complications of WNV in an immunocompromised host.

Cerebral revascularization in cerebral proliferative angiopathy: a systematic review.

OBJECTIVECerebral proliferative angiopathy (CPA) is considered a discrete vascular malformation of the brain separate from classical brain arteriovenous malformations (AVMs). It has unique angiographic characteristics and has been hypothesized to result from chronic cortical ischemia and perinidal oligemia. Treatment with cerebral revascularization has been proposed in an attempt to disrupt regional hypoperfusion and interrupt the angiogenesis that defines CPA. A systematic review of the literature pertaining to the role of cerebral revascularization may highlight a treatment paradigm for this rare disease.METHODSA systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. MEDLINE and Embase were searched from inception for papers relating to CPA. Included articles were categorized according to methodology (case series or imaging study) and treatment modality (conservative, radiation, endovascular, or revascularization). A synthesis was compiled summarizing the current evidence regarding cerebral revascularization in CPA.RESULTSThe initial search revealed 43 articles, of which 28 studies met the inclusion criteria. Nine studies were identified that described imaging findings, which suggested hemodynamic dysregulation and perinidal impairments in the cerebrovascular reserve could be identified compared to unaffected hemispheres and classical brain AVMs. Six studies including 7 patients undergoing indirect forms of cerebral revascularization were identified. Clinical and radiological outcomes following revascularization were favorable in all but one study.CONCLUSIONSA small body of radiological and clinical studies has emerged, suggesting that CPA is a response to perinidal oligemia. While the long-term clinical efficacy of revascularization remains unclear, early results suggest that this may be a novel treatment paradigm for patients with CPA.

Gonococcal meningitis: An unusual presentation of disseminated gonococcal infection.

Gonorrhea is a sexually transmitted infection caused by Neisseria gonorrhoeae. The rate of N. gonorrhoeae infections in Canada has increased from 2010 to 2015. Disseminated gonococcal infection typically results from bacteremic spread of N. gonorrhoeae from a preceding mucosal site of disease (e.g., urogenital). Common clinical manifestations of disseminated gonococcal infection include skin lesions, tenosynovitis, and septic arthritis. Bacterial meningitis as a manifestation of disseminated gonococcal infection has been rarely described. A case of bacterial meningitis due to N. gonorrheae, complicated by an ischemic stroke, is reported here. Clinical features that may point to N. gonorrhoeae as the pathogen in a patient with bacterial meningitis include a concomitant active urogenital infection, skin rash, arthritis, and/or tenosynovitis. Parenteral ceftriaxone for 10 to 14 days combined with a single oral dose of azithromycin is currently recommended as the treatment for gonococcal meningitis in recent guidelines. This case is presented to highlight a potential, albeit rare, complication of a preventable disease that has resurged in the last decade in our community.

La gonorrhée est une infection transmise sexuellement causée par la Neisseria gonorrhoeae. Le taux d'infection par la N. gonorrhoeae a augmenté au Canada entre 2010 et 2015. L'infection gonococcique disséminée est généralement causée par la transmission bactériémique de la N. gonorrhoeae à partir d'un autre siège d'infection muqueux (p. ex., système urogénital). Les lésions cutanées, la ténosynovite et l'arthrite septique sont des manifestations cliniques courantes de l'infection gonococcique disséminée, mais la méningite bactérienne est rarement décrite. Les auteurs rendent compte d'un cas de méningite bactérienne attribuable à la N. gonorrheae, compliqué par un accident ischémique cérébral. Plusieurs caractéristiques cliniques peuvent laisser présager que la N. gonorrhoeae en est l'agent pathogène, telles qu'une infection urogénitale active simultanée, une éruption cutanée, l'arthrite et une ténosynovite. Selon les directives récentes, l'administration de ceftriaxone par voie parentérale pendant dix à 14 jours, combinée à une monodose d'azithromycine par voie orale, est actuellement recommandée pour traiter la méningite gonococcique. Le présent cas est présenté pour faire ressortir une complication potentielle, mais rare, d'une maladie évitable qui a refait surface dans la collectivité depuis dix ans.

Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke.

OBJECTIVE: Shorter time from symptom onset to treatment is associated with improved outcomes in patients who undergo mechanical thrombectomy for treatment of acute ischemic stroke due to emergent large vessel occlusion. In this work, we detail pre-thrombectomy process improvements in a multi-hospital network and report the effect on door-to-puncture time in patients undergoing mechanical thrombectomy. PATIENTS AND METHODS: A streamlined workflow was adopted to minimize door-to-puncture time. Key features of this workflow included rapid and concurrent clinical and radiological evaluation with point-of-care image interpretation, pre-transfer IV thrombolysis and CTA for transferred patients, immediate transport to the angiography suite potentially before neurointerventional radiology team arrival, and minimalist room setup. Door-to-puncture time was measured prospectively and analyzed retrospectively for 78 consecutive patients treated between January 2015 and December 2015. Statistical analysis was performed using the F-test on individual coefficients of a linear regression model. RESULTS: From quarter 1 to quarter 4, the number of thrombectomies performed increased by 173% (11 patients to 30 patients, p = 0.002), and there was a significant increase in the proportion of transferred patients that underwent pre-transfer CTA (p = 0.04). During this interval, overall median door-to-puncture time decreased by 74% (147 min to 39 min, p < 0.001); this decrease was greatest in transferred patients with pre-transfer CTA (81% decrease, 129 min to 25 min, p < 0.001) and smallest in patients presenting directly to the emergency department (52% decrease, 167 min to 87 min, p < 0.001). CONCLUSION: Simple workflow improvements to streamline in-hospital triage and perform critical workup at transferring hospitals can produce reductions in door-to-puncture time.

Unusual high-grade features in pediatric diffuse leptomeningeal glioneuronal tumor: comparison with a typical low-grade example.

Diffuse leptomeningeal glioneuronal tumor, a recent addition to the World Health Organization classification system, typically presents in the pediatric population with signs and symptoms related to elevated intracranial pressure and imaging characteristics that may mimic infectious etiologies. The tumor is usually low grade and tends to harbor BRAF rearrangement/duplication in up to 75% of cases, BRAF V600E mutation in a smaller subset of cases, and loss of chromosomal arm 1p in approximately 50%-60% of cases, with ~20% of those showing loss of both 1p and 19q (codeletion). We report here 2 contrasting cases of diffuse leptomeningeal glioneuronal tumors, one with typical low-grade features and an indolent, although not benign, course, in which the disease is currently successfully managed by chemotherapy, and a second case with unusually high-grade features on initial presentation, including frank anaplasia and elevated mitotic index, in which the disease showed an initial response to chemoradiation but ultimately was fatal.

Intra-arterial versus intravenous abciximab therapy for thromboembolic complications of neuroendovascular procedures: case review and meta-analysis.

BACKGROUND: Abciximab is used to treat thromboembolic complications of neuroendovascular procedures, but outcomes of treatment are not well defined. OBJECTIVE: To examine the angiographic and clinical outcomes based on route of abciximab administration and degree of vessel recanalization. MATERIALS AND METHODS: A prospectively maintained database of neuroendovascular procedures performed between January 2004 and May 2015 was retrospectively reviewed to identify cases with thromboembolic complications treated with abciximab. In these cases, route of administration, degree of vessel recanalization, and presence or absence of infarction were determined. A meta-analysis of similar cases in the literature was also performed. RESULTS: Abciximab was administered in 0.24% (47 of 19 566) of procedures to treat thromboemboli in 59 vessels. Angiographic improvement was seen in 94% after IA therapy and 79% after IV therapy (p=0.133). In our meta-analysis of 391 treated patients, angiographic improvement was greater after IA (91.7%) than IV (77.4%) treatment (p<0.001). Postprocedural infarction occurred more frequently with distal lesions (42%) than local lesions (12%) (p=0.014), and occlusive lesions (36%) than non-occlusive lesions (4.8%) (p=0.010). Infarction was significantly less common with complete angiographic resolution (0%) than with partial or no improvement (54%) (p<0.001). Symptomatic intracranial hemorrhage occurred in 2.1%. CONCLUSIONS: Abciximab produces a high rate of angiographic improvement and a low incidence of postprocedural infarct in neuroendovascular procedures complicated by thromboemboli. IA abciximab produces greater angiographic improvement than IV treatment. Postprocedural infarction is less common in patients with complete angiographic response than in those with partial or no response.

Evolution of endovascular stroke therapies and devices.

Acute ischemic stroke is caused by occlusion of a cerebral artery, resulting in loss of brain tissue and neurologic deficits. However, a portion of the ischemic brain can be salvaged if blood flow is restored within an appropriate time frame. The past year has seen the publication of five positive randomized controlled trials demonstrating substantial benefit of mechanical thrombectomy in select patients with large vessel cerebrovascular occlusion. This progress is related to several factors, but most importantly, dramatic improvements in speed and rates of recanalization with the latest generation devices. In this article, we review the evolution of endovascular acute ischemic stroke therapies and key design features of the most widely used devices.

Radiological errors in the Canadian Journal of Emergency Medicine.

OBJECTIVES: To systematically evaluate the accuracy of text descriptions and labeling of radiologic images published in the Canadian Journal of Emergency Medicine (CJEM). Error detection by radiologists and emergency physicians and the clinical significance and educational value of these errors were assessed. Errors were also correlated with radiologist involvement in publication and imaging modality. METHODS: Thirty-three issues of CJEM were examined from January 2003 to May 2008. Electronic copies of all radiologic images published were obtained with their caption and description from the text. Identifying information was removed to present images in an anonymous fashion. Images were presented to two radiologists who, working in consensus, critically appraised each image and accompanying text. Images were then presented to two emergency department physicians who, working in consensus, critically appraised each image and accompanying text. All images with errors detected by either radiology or emergency physicians were then discussed to determine if errors would have affected clinical management or educational value. The emergency physicians also identified "underlabeled" images where it was felt that further labeling would enhance their educational value. RESULTS: Forty-five articles with 82 images were obtained. At least one error was observed in 18 (40%) articles and 20 (24%) images. Two errors were present in three images, resulting in 23 errors. Of the 23 errors, 17 were image description errors and 6 were labeling errors. Five errors were detected by both radiology and emergency physicians, whereas 15 were detected only by radiologists and 3 were detected only by emergency physicians. Of these errors, 12 (52%) were rated as potentially affecting both clinical management and educational value, 5 (22%) as only affecting educational value, and 6 (26%) as nonsignificant. Radiologists were involved in six articles, including 12 images that contained no errors. There was no official radiologist involvement in 39 articles, including 70 images, 18 (26%) of which contained errors. In addition, 26 images were identified by emergency physicians as potentially benefiting from enhanced labeling to improve educational value. CONCLUSIONS: Radiologic images published in the CJEM are generally of high quality; however, 23 errors were found in 82 images, 18 (78%) of which were rated as potentially affecting clinical management, educational value, or both. Radiologist involvement in the publication process may be of assistance as no errors were seen in articles that included radiologists as authors.

Adenoma malignum detected on a trauma CT.

Adenoma malignum is a rare subtype of cervical adenocarcinoma. Clinical presentation is variable with watery vaginal discharge being the most commonly associated finding. We report a case of adenoma malignum incidentally detected on pelvic computed tomography (CT) performed for a trauma patient. The cervical mass was further characterized by magnetic resonance (MR) imaging and remained compatible with adenoma malignum. Local cervical biopsy was suggestive of the diagnosis which was subsequently confirmed by gross surgical pathology. We briefly discuss adenoma malignum with particular attention to CT and MR imaging features.