Stenting as a treatment for cranio-cervical artery dissection: Improved major adverse cardiovascular event-free survival.

INTRODUCTION: Cranio-cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement. METHODS: COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥ 18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1 year evaluating MACE as the primary endpoint. RESULTS: One-hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including sneezing, carrying heavy load, chiropractic manipulation. Stent was placed in 10 (10%) subjects (extracranial carotid n = 9; intracranial carotid n = 1; extracranial vertebral n = 1) at the physician's discretion along with medical management. Reasons for stent placement were early development of high-grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in-hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year. CONCLUSION: In this single high-volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high-grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

Repair of Temporal Bone Defects via the Middle Cranial Fossa Approach: Treatment of 2 Pathologies With 1 Operation.

BACKGROUND: Temporal bone dehiscence (TBD) often results in leakage of cerebrospinal fluid (CSF) and/or encephalocele. TBD can also occur over the superior semicircular canal, causing debilitating vertigo. Both can be repaired surgically, but traditional treatment is focused only on one pathology, not both. OBJECTIVE: To report our experience in the treatment of TBD via the middle cranial fossa (MCF) approach. METHODS: A retrospective review was conducted for all patients who underwent MCF approach for surgical repair of any temporal fossa dehiscence. RESULTS: A total of 34 patients underwent a total of 37 surgeries. Obesity was prevalent; 21 patients (61.8%) were obese (BMI [body mass index] > 30 kg/m2), and 7 (20.6%) were overweight (BMI 25-30 kg/m2). The most common presenting symptom was hearing disturbance (70.3%), followed by otorrhea (51.4%). Empty sella was noted on computed tomography or magnetic resonance imaging in 15 patients (45.5%). Eight of the 34 patients (23.5%) were found to have superior semicircular canal dehiscence (SCD). Hearing improved with surgical intervention in 25 of 26 patients with hearing loss as a presenting symptom (96%). CSF resolved in 18 of 19 cases (95%). Seventy-three percent of patients reported at least minimal improvement in vertigo. CONCLUSION: TBD may present with symptoms of CSF leak/encephalocele, but may also present with superior SCD. We recommend consistent review of the temporal bone imaging to check for superior SCD, and repair of the SCD first to prevent complications involving the labyrinth and cochlea. MCF approach using a multilayer repair without a lumbar drain is highly effective with minimal risk of complications.

Nontraumatic Subdural Hematoma and Intracystic Hemorrhage Associated with a Middle Fossa Arachnoid Cyst.

Intracranial arachnoid cysts (ACs) are relatively common findings that can be seen in up to 2% of patients. They are generally found incidentally with a benign clinical course and can be usually managed by observation. We report an unusual case of a middle fossa AC presenting with spontaneous intracystic hemorrhage along with subdural hematoma (SDH) causing significant mass effect and midline shift requiring surgical treatment. Even though the risk of hemorrhage in patients with AC is very low, the presence of AC is a known risk factor for SDH. Fortunately, the clinical outcome of patients who present with hemorrhage associated with AC is generally favorable with early recognition and prompt surgical treatment. Our case highlights the fact that both intracystic hemorrhage and SDH can occur in association with AC even in the absence of trauma and should be kept in mind when counseling patients with incidental AC about the natural history of these lesions.

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.

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.

Monoplane 3D Overlay Roadmap versus Conventional Biplane 2D Roadmap Technique for Neurointervenional Procedures.

PURPOSE: We investigated whether a 3D overlay roadmap using monoplane fluoroscopy offers advantages over a conventional 2D roadmap using biplane fluoroscopy during endovascular aneurysm treatment. MATERIALS AND METHODS: A retrospective chart review was conducted for 131 consecutive cerebral aneurysm embolizations by three neurointerventionalists at a single institution. Allowing for a transition period, the periods from January 2012 to August 2012 (Time Period 1) and February 2013 to July 2013 (Time Period 2) were analyzed for radiation exposure, contrast administration, fluoroscopy time, procedure time, angiographic results, and perioperative complications. Two neurointerventionalists (Group 1) used a conventional 2D roadmap for both Time Periods, and one neurointerventionalist (Group 2) transitioned from a 2D roadmap during Time Period 1 to a 3D overlay roadmap during Time Period 2. RESULTS: During Time Period 2, Group 2 demonstrated reduced fluoroscopy time (p<0.001), procedure time (P=0.023), total radiation dose (p=0.001), and fluoroscopy dose (P=0.017) relative to Group 1. During Time Period 2, there was no difference of immediate angiographic results and procedure complications between the two groups. Through the transition from Time Period 1 to Time Period 2, Group 2 demonstrated decreased fluoroscopy time (p< 0.001), procedure time (p=0.022), and procedure complication rate (p=0.041) in Time Period 2 relative to Time Period 1. CONCLUSION: The monoplane 3D overlay roadmap technique reduced fluoroscopy dose and fluoroscopy time during neurointervention of cerebral aneurysms with similar angiographic occlusions and complications rate relative to biplane 2D roadmap, which implies possible compensation of limitations of monoplane fluoroscopy by 3D overlay technique.

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.

Minimally invasive evacuation of intraventricular hemorrhage with the Apollo vibration/suction device.

Intraventricular hemorrhages (IVH) can occur as a consequence of spontaneous intracerebral hemorrhage, aneurysm rupture, arteriovenous malformation hemorrhage, trauma, or coagulopathy. IVH is a known risk factor for poor clinical outcome with up to 80% mortality. The current standard treatment strategy for IVH consists of the placement of an external ventricular drain. We report our early experience with using the Apollo suction/vibration aspiration system (Penumbra, Alameda, CA, USA) for minimally invasive evacuation of IVH with a review of the pertinent literature. Medical records of patients with IVH who were admitted to Rush University Medical Center, USA, from July to November 2014 were queried from the electronic database. Patients with Graeb Scores (GS) >6 were selected for minimally invasive IVH evacuation with the Apollo aspiration system. Patient demographics, pre- and post-operative GS, pre- and post-operative modified Graeb Score (mGS), as well procedure related complications were analyzed and recorded. A total of eight patients (five men) were identified during the study period. The average age was 55.5years. The mean GS was 9.6 pre-operatively and decreased to 4.9 post-operatively (p=0.0002). The mean mGS was 22.9 pre-operatively and decreased to 11.4 post-operatively (p=0.0001). Most of the IVH reduction occurred in the frontal horn and atrium of the lateral ventricle, as well the third ventricle. One (1/8) procedure-related complication occurred consisted of a tract hemorrhage. The Apollo system can be used for minimally invasive IVH evacuation to achieve significant blood clot volume reduction with minimal procedure-related complication.

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.

Arteriovenous malformation embocure score: AVMES.

BACKGROUND: Cerebral arteriovenous malformations (CAVMs) may be treated with microsurgery, radiosurgery, endovascular surgery, or a combination of these modalities. Grading scales are available to aid the assessment of curative risk for microsurgery and radiosurgery. No grading system has been developed to assess the curative risk of endovascular surgery. OBJECTIVE: To report our retrospective application of the AVM embocure score to patients treated at our institution between 2005 and 2011 METHODS: We performed a retrospective review of 39 patients with CAVM treated at our institution between 2005 and 2011 with the primary aim of achieving a curative embolization. After reviewing all the different variables associated with the conventional Onyx embolization technique for CAVMs, we identified the following as the most relevant characteristics influencing the chances for complete angiographic embolization and complication risk: the number of arterial pedicles and draining veins, size of AVM nidus, and vascular eloquence. We sought to develop a scoring system to assess the complication risk for a curative embolization of CAVM with liquid embolic Onyx (Covidien, Irvine, California, USA). We developed the AVM embocure score (AVMES). This scoring system ranges from 3 to 10 and is the arithmetic sum of the number of arterial pedicles feeding the AVM (≤3, 4-6, >6), the number of draining veins (≤3, 4-6, >6), the size of the AVM nidus in centimeters (≤3, 4-6, >6), and the vascular eloquence (0-1). We applied AVMES to the same cohort of patients and validated the predictability of complete angiographic embolization and expected clinical risk of complication. RESULTS: In lesions with an AVMES of 3 (n=8), there was a 100% rate of complete AVM obliteration and 0% rate of major complications. In AVMES 4 (n=12) lesions, there was 75% complete obliteration rate, with 8% major morbidity. In AVMES 5 (n=9) lesions, there was 78% complete obliteration and 11% major morbidity. In AVMES >5 (n=10) there was 20% complete obliteration and 30% major morbidity. Receiver-operator curve analysis showed that this scoring system was robust in its discriminative ability, with an area under the curve (AUC) of 0.8356 for complete obliteration without complication, AUC=0.8240 for complete obliteration regardless of the presence of major morbidity, and AUC=0.7529 for major morbidity. CONCLUSIONS: The AVMES complements existing scoring systems for microsurgery and radiosurgery. It provides a valuable tool for risk assessment during the complex decision-making process in treating AVMs that accounts for angioarchitectural features of particular relevance to endovascular surgeons.

Intrasphenoidal Rathke's cleft cyst.

We report a rare patient with an intrasphenoidal Rathke's cleft cyst (RCC) and review the literature. RCC are benign epithelium lined cysts containing mucoid material, which typically occur in a location that is either entirely intrasellar, or intrasellar with suprasellar extension (intra-suprasellar). RCC in a completely extrasellar location are uncommon. An intrasphenoidal RCC is extremely rare with only two patients reported in the literature to date. Preoperative diagnosis is difficult due to the uncommon location and absence of any characteristic radiological features. However, it remains of utmost clinical relevance because it may limit the operative management to biopsy sampling of the cyst wall and drainage of the contents via the transsphenoidal route.

Ventriculoperitoneal shunt in a patient with ruptured blister aneurysm treated with pipeline embolization device.

Cerebral spinal fluid (CSF) diversion is frequently required in patients with aneurysmal subarachnoid hemorrhage who develop subsequent hydrocephalus. Procedures such as external ventricular drain (EVD) and ventriculoperitoneal shunt (VPS) usually carry a very low rate of complications. However, as flow diverting stents such as Pipeline Embolization Device (PED) become more widely available, flow diverters are being used in treatment of some ruptured complex aneurysms. EVD and VPS placement in the setting of dual antiplatelet therapy (DAT) in these patients are associated with a significant risk of intracranial hemorrhage. We describe a management strategy and surgical technique that can minimize hemorrhagic complications associated with VPS in patients on DAT after treatment with flow diverting stents.

High cervical spinal subdural hemorrhage as a harbinger of craniocervical arteriovenous fistula: an unusual clinical presentation.

BACKGROUND CONTEXT: Craniocervical dural arteriovenous fistula (dAVF) is rare as compared with the typical thoracolumbar dAVFs of the spine and usually presents with hemorrhagic manifestation, predominantly intracranial subarachnoid hemorrhage. PURPOSE: We describe the first case of craniocervical dAVF with initial presentation as neck pain and spinal subdural hemorrhage. STUDY DESIGN: Case report. METHODS: We present the case of a 59-year-old woman who presented with sudden onset of neck pain at an outside institution emergency department (ED) and was discharged after negative cervical spine radiographs. Magnetic resonance imaging of the cervical spine performed because of persistent pain demonstrated presence of high cervical spinal subdural hematoma and she was managed conservatively. She subsequently presented to our ED a week later with headache and was found to have an intraventricular hemorrhage on computed tomography scan of the head, which on subsequent workup with an angiography revealed the presence of a craniocervical dAVF. RESULTS: Surgical obliteration of the fistula was performed with use of intraoperative angiography as an adjunct to confirm complete fistula obliteration. She had an excellent clinical outcome with no deficits at her last follow-up at 9 months. CONCLUSIONS: Even though hemorrhagic presentation is fairly common in craniocervical dAVFs, there is no report of a craniocervical dAVF presenting with spinal subdural hemorrhage. The present case further highlights the propensity of these vascular lesions to bleed and emphasizes the clinical importance of including these lesions in the differential diagnosis of hemorrhage in the vicinity of foramen magnum region, whether subarachnoid or subdural in location. Physicians treating spinal pathologies should be aware of this entity and clinical presentation, as an angiography needs to be considered in these cases to direct appropriate referral and treatment.

Outcome following intracranial hemorrhage associated with novel oral anticoagulants.

The emergence of dabigatran, rivaroxaban and apixaban has changed the approach to anticoagulation for patients worldwide. Continued approval of novel oral anticoagulants (NOAC) for non-valvular atrial fibrillation and venous thromboembolism will result in increasing use of these medications over warfarin. Morbidity and mortality of anticoagulant related intracranial hemorrhage (ICH) is relatively high and there is concern that outcomes may be worse with NOAC as there is a lack of specific antidotes for these agents with a greater risk for hematoma expansion. Unfortunately, the evidence supporting effective reversal strategies is lacking. Therefore, to gain further insight into the outcome after the management of NOAC related ICH, we present our experience with two patients with NOAC-induced ICH.

Recovery of pituitary function following treatment of an unruptured giant cavernous carotid aneurysm using Surpass flow-diverting stents.

Giant aneurysms arising from the cavernous internal carotid artery (ICA) can mimic pituitary adenomas and may cause pituitary dysfunction due to their mass effect on the pituitary gland. We report a case of a 56-year-old man presenting with impotence, fatigue and panhypopituitarism who was found to have a giant unruptured aneurysm arising from the right cavernous ICA with severe mass effect on the pituitary gland. The patient underwent endovascular treatment of the giant aneurysm using two telescoping Surpass flow-diverting stents. At 6-month follow-up, repeat cerebral angiography showed Raymond grade II occlusion of the aneurysm with a small neck remnant. At the 10-month follow-up the patient showed full recovery of his pituitary function and clinical resolution of impotence and fatigue. This is the first report of occlusion of a giant cavernous carotid aneurysm using next generation Surpass flow-diverting stents leading to complete recovery of pituitary function.

Thromboembolic complications with Pipeline Embolization Device placement: impact of procedure time, number of stents and pre-procedure P2Y12 reaction unit (PRU) value.

BACKGROUND: Thromboembolic events after Pipeline Embolization Device (PED) placement remain a feared complication among neuroendovascular surgeons. This study aimed to investigate potential risk factors for thromboembolic events in patients undergoing PED placement. METHODS: Medical records of patients who underwent PED placement from April 2011 to August 2013 were reviewed. Variables including pre-procedure P2Y12 reaction unit (PRU) value, procedure time, number of PEDs deployed and perioperative neurovascular complications were recorded. Multivariate analysis was performed to identify risk factors for perioperative thromboembolic complications. RESULTS: Seventy-four patients were identified. Six patients (8.1%) had changes in neurological status after PED placement including five (6.8%) thromboembolic complications and one (1.4%) delayed intracranial hemorrhage; 50.9% of patients had diffusion-weighted imaging (DWI) changes on post-procedural MRI. Longer procedure time (>116 min) and multiple PED placements (>1) were statistically significant risk factors for symptomatic thromboembolic events (p<0.01). A pre-procedural PRU value >208 had an OR of 11.32 (95% CI 0.06 to 212.57) for symptomatic thromboembolic complications, but the result was not statistically significant. CONCLUSIONS: DWI changes on MRI occurred at a much higher rate than new neurological symptoms following PED placement. Longer procedure time and multiple PED deployment are associated with higher risks of new neurological changes due to thromboembolic events. There was a trend for an increased risk of a symptomatic thromboembolic event in patients with pre-procedural PRU values >208. Reloading (clopidogrel 600 mg) patients with preoperative PRU >208 was safe and may have a protective effect on thromboembolic events.

Preliminary in vivo evaluation of a novel intrasaccular cerebral aneurysm occlusion device.

OBJECTIVE: Current endovascular technology does not offer a perfect solution for all cerebral aneurysms. Our group has built two versions of a novel aneurysm intrasaccular occlusion device (AIOD) to address the drawbacks associated with current occlusion devices. The objective of the present study was to perform pilot proof of concept in vivo testing of this new AIOD in swine and canines. METHODS: Two configurations of the AIOD, termed 'coil-in-shell' and 'gel-in-shell', were implanted in surgically created sidewall aneurysms (n=4) in swine for acute occlusion studies, as well as sidewall (n=8) and bifurcation aneurysms (n=3) in canines to assess long term occlusion efficacy. Occlusion at all time points (immediate, 6 weeks, and 12 weeks) was evaluated by angiography. Neointimal healing at 12 weeks post-implantation in canines was examined histologically. RESULTS: Angiographic analysis showed that both the coil-in-shell and gel-in-shell devices achieved complete aneurysm occlusion immediately following device delivery in sidewall aneurysms in swine. In longer term canine studies, initial occlusion ranged from 71.3% to 100%, which was stable with no recurrence in any of the sidewall aneurysms at 6 or 12 weeks. Histological analysis at 12 weeks showed mature fibromuscular tissue at the neck of all aneurysms and no significant inflammatory response. CONCLUSIONS: The AIOD tested in this study showed promise in terms of acute and chronic occlusion of aneurysms. Our findings suggest that these devices have the potential to promote robust tissue healing at the aneurysm neck, which may minimize aneurysm recurrence. Although proof of principle has been shown, further work is needed to deliver this device through an endovascular route.

Compressive optic neuropathy secondary to a lateral rectus muscle dermoid cyst.

A 48-year-old man presented 2 weeks after sudden OS vision loss. On examination, the patient had decreased OS visual acuity, an ipsilateral afferent pupil defect, and proptosis. MRI of the orbit with and without gadolinium showed a large, enhancing heterogeneous mass extending to the orbital apex. Uncomplicated resection was performed and pathology was consistent with a dermoid cyst. Postoperatively, the patient had improved visual acuity and minimal lateral rectus dysfunction. There are only 4 reported cases of dermoid cysts located within the lateral rectus muscle, albeit this is the first case describing a compressive optic neuropathy in the setting of an orbital dermoid cyst.