Are modified Fisher Scale and bleeding pattern helpful predictors of neurological complications in non-aneurysmal subarachnoid hemorrhage?

PURPOSE: Non-aneurysmal subarachnoid hemorrhage (NA-SAH) is a clinical-radiological entity with a different prognosis than aneurysmal SAH (A-SAH). The purpose of this study is to assess the predictive value of the modified Fisher Scale (mFS) for neurological complications in patients with this diagnosis. METHODS: We recruited patients admitted at our hospital services between 2009 and 2017 who were diagnosed with spontaneous SAH, with either perimesencephalic (PM-SAH) or diffuse pattern (D-SAH), an initial negative angio-CT, and at least one digital subtraction angiography of brain vessels discarding underlying brain aneurysms or other vascular malformations. RESULTS: The retrospective observational study included 116 patients. The mean age was 54.4, and the sample included predominantly male subjects (62.9%). Hunt and Hess (HH) scores on admission ranged from 3 to 5 in 18.1% of patients. The prevalence of hydrocephalus requiring ventricular drainage was 18.1%. The prevalence of symptomatic vasospasm was 4.3%. A modified Rankin Scale (mRS) 0-2 at discharge was found in 95.6%. In a multivariate logistic regression for the presence of neurological complications including age, sex, admission HH 3-5 compared with < 3, mFS 4 compared with mFS < 4, D-SAH compared with PM-SAH, and mRS score at discharge of 0-2 compared with > 2, the only significant predictors were mFS 4 compared with mFS < 4 (OR 4.47 (95% CI 1.21, 16.66) p value = 0.03) and D-SAH compared with PM-SAH (OR 7.10 (95% CI 1.24, 40.8) p value = 0.03). CONCLUSION: In patients with NA-SAH, a mFS score of 4 and/or a D-SAH bleeding pattern in non-contrast cranial CT on admission predicted the development of relevant neurological complications.

Diagnóstico de pacientes con sospecha de COVID-19: ¿Cuál es el rol de la TC de tórax? / Diagnosis of patients with suspected COVID-19: What is the role of chest CT?

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Transcirculation Approach for Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Study and Review of the Literature.

Background: Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, provide alternate endovascular routes when anterograde interventions are not feasible. We aimed to assess the safety and efficacy of mechanical thrombectomy (MT) through a transcirculation route. Methods: Six centers provided retrospective data on acute ischemic stroke (AIS) patients who underwent MT via transcirculation approaches. Demographics and technical details of the endovascular intervention were collected. Recanalization rates, peri-procedural complications and clinical/angiographic outcomes immediately after the procedure and at last available follow-up were assessed. A review of the literature reporting on AIS patients whom underwent transcirculation MT was also performed. Results: Our multicenter study included 14 AIS patients treated through transcirculation routes. Mean age was 57.8 ± 11.9 years, and 10 (71.4%) were men. Mean NIHSS at admission was 18.4 (range 8-27). TICI 2b-3 recanalization was achieved in 10/14 (71.4%) patients. Three patients died after intervention: one due to late recanalization, one due to acute in-stent thrombosis, and one due to a procedure-related thromboembolic brainstem infarct. Of 11 surviving patients with follow-up available (mean 9.7 months), mRS 0-2 was achieved in 6 (54.5%) cases. Our review of the literature pooled a total of 37 transcirculation MT cases. Most common occlusions were tandem lesions (ICA + MCA = 64.9%) and BA + bilateral VA (18.9%). ACOM and PCOM were crossed in 18 (48.6%) cases each; one patient required a combined ACOM-PCOM approach. Primary recanalization technique included intra-arterial (IA) thrombolytics alone in 10 (27%), angioplasty ± stenting in 6 (16.2%), stent-retriever in 8 (21.6%), contact aspiration in 6, and combined (MT ± IA-thrombolytics) in 6 cases. Twenty-eight (75.7%) AIS patients achieved successful TIMI 2-3/TICI 2b-3 recanalization. After a mean follow-up of 6.7 months, 23/31 (74.2%) patients achieved a favorable functional outcome. Conclusions: Transcirculation approaches may be used to access the target lesion when the parent artery cannot be crossed through conventional antegrade routes. These techniques are feasible but should be reserved as a bailout maneuver when anterograde MT is not possible. Newer endovascular devices have improved neurological and angiographic outcomes in transcirculation cases.

Hemorragia subaracnoidea con angiotomografía negativa sin vasoespasmo: ¿es necesario realizar controles angiográficos? / Subarachnoid haemorrhage with negative tomographic angiography without vasospasm: is it necessary to perform angiographic controls?

INTRODUCCIÓN: Aproximadamente en un 15% de los casos, la lesión causante de hemorragia subaracnoidea (HSA) no es detectable por estudios de imagen, y existe controversia sobre cómo debe ejecutarse el diagnóstico en estos pacientes. OBJETIVO: Analizar el rendimiento diagnóstico de las angiografías por sustracción digital (ASD) realizadas en una cohorte significativa de pacientes con HSA y angiotomografía negativa, sin vasoespasmo cerebral, basándose en la distribución del sangrado en la tomografía computarizada simple. PACIENTES Y MÉTODOS: Se realiza un análisis retrospectivo de la base de datos radiológica del centro en un período de ocho años. Los criterios de inclusión fueron pacientes con HSA de distribución perimesencefálica o difusa con resultado negativo en la angiotomografía, sin vasoespasmo cerebral, con al menos un control realizado mediante ASD de los vasos cerebrales. RESULTADOS: Un total de 125 pacientes cumplieron los CRITERIOS DE INCLUSIÓN: 61 tenían una HSA perimesencefálica y 64 presentaban una HSA difusa. La primera ASD reveló una lesión vascular en siete pacientes (5,6%): uno de ellos correspondía al grupo de HSA perimesencefálica (rendimiento del 1,6%) y seis al de HSA difusa (rendimiento del 9,4%). Se realizó una segunda ASD en 86 pacientes, una tercera en 28 y una cuarta en cinco. Ninguno de estos estudios reveló la presencia de lesiones causantes de la HSA. CONCLUSIÓN: La ausencia de vasoespasmo en la primera ASD realizada en pacientes con HSA y angiotomografía negativa podría ser un criterio útil para establecer un protocolo óptimo de seguimiento en estos pacientes, sin exponerlos a riesgos y radiación innecesarios

INTRODUCTION: In about 15% of cases, the lesion causing subarachnoid haemorrhage (SAH) is not detectable by imaging studies, and some controversy exists as regards how the diagnosis should be performed in these patients. AIM: To analyse the diagnostic performance of digital subtraction angiography (DSA) carried out on a significant cohort of patients with SAH and negative tomographic angiography, without cerebral vasospasm, based on the distribution of bleeding in a simple CT scan. PATIENTS AND METHODS: A retrospective analysis is performed of the centre’s radiological database over an eight-year period. The inclusion criteria were patients with SAH of a perimesencephalic or diffuse distribution with a negative tomographic angiography result, without cerebral vasospasm, with at least one DSA control of the brain vessels. RESULTS: A total of 125 patients met the inclusion criteria: 61 had a perimesencephalic SAH and 64 had a diffuse SAH. The first DSA revealed vascular injury in seven patients (5.6%): one was in the perimesencephalic SAH group (1.6% yield) and six in the diffuse SAH group (9.4% yield). A second DSA was performed on 86 patients, a third on 28 and a fourth on five of them. CONCLUSION: The absence of vasospasm in the first DSA performed in patients with SAH and negative tomographic angiography could be a useful criterion for establishing an optimal follow-up protocol in these patients, without exposing them to unnecessary risks and radiation

Transcirculation Approach for Endovascular Embolization of Intracranial Aneurysms, Arteriovenous Malformations, and Dural Fistulas: A Multicenter Study.

BACKGROUND: Unfavorable anatomy can preclude traditional anterograde endovascular interventions. Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, can provide alternative pathways for successful treatment of these patients. We aimed to assess the safety, efficacy, and outcomes of endovascular embolization through transcirculation approaches. METHODS: Nine centers provided retrospective data on patients who underwent transcirculation procedures for embolization of intracranial aneurysms (IAs), dural arteriovenous fistulas (dAVFs), and arteriovenous malformations (AVMs). Raymond-Roy Occlusion Classification (RROC) grades and degree of obliteration were used to evaluate treatment success. Minor/major complications and clinical/angiographic outcomes were also assessed. A review of the literature reporting patients who underwent transcirculation embolizations was also performed. RESULTS: Forty patients were included in the study (34 IAs, 3 AVMs, and 3 dAVFs). Most IAs (22/34, 64.7%) were treated electively. Three AVMs and 2 dAVFs presented ruptured. RROC grade I-II was achieved in 97% of IAs. All AVMs and dAVFs were completely obliterated. One patient developed a transient arterial thrombus that was successfully treated with intravenous tirofiban. The most common indications for a transcirculation approach were difficult access angle of the target lesion (42.5%) and occlusion of the parent artery (27.5%). The review of the literature pooled 152 IAs treated via transcirculation approaches. Most common locations were the basilar tip (27%), posterior inferior cerebellar artery (25%), and internal carotid artery (15.1%). The posterior communicating artery was crossed in 60 (39.5%), anterior communicating artery in 48 (31.6%), and vertebral artery in 37 (24.3%) patients. Primary coiling alone was performed in 22 (14.5%), stent-assisted coiling in 67 (44.1%), balloon-assisted coiling in 36 (23.7%), stent-assisted coiling + balloon-assisted coiling in 20 (13.2%) and flow diversion in 7 (4.6%) patients. After intervention, 142 (93.4%) IAs achieved successful RROC grades I-II. Two major complications (1.3%) leading to death were reported, both of which were intraprocedural aneurysmal ruptures with massive subarachnoid hemorrhage and herniation. After a mean angiographic follow-up of 11.3 months, only 6/108 (5.6%) IAs showed intrasaccular filling/recurrence. CONCLUSIONS: Transcirculation approaches seem to be safe and effective in the treatment of IAs, dAVFs, and AVMs. The most common indication for a transcirculation approach is the presence of a difficult angle to access the target lesion and occlusion of the parent artery.

Gota que simula tumoración de partes blandas / Gout mimicking soft tissue tumor

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Infartos estratégicos del tálamo: una causa infrecuente de demencia vascular / Strategic infarcts of the thalamus: an uncommon cause of vascular dementia

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Sinusitis fúngica invasiva crónica: hallazgos radiológicos característicos / Chronic invasive fungal sinusitis: characteristic radiological findings

Paciente masculino de 77 años con antecedentes de diabetes mellitus no controlada y hepatitis B en tratamiento con entecavir; consultó por cefalea frontoorbitaria derecha, de carácter continuo, con tres meses de evolución y aumento súbito de su intensidad. El examen neurológico no reveló focalidad y ante la severidad del cuadro se decidió realizar una TC cerebral. En este estudio se observó ocupación parcial de las celdillas etmoidales, hallazgo que sugirió sinupatía aguda (foto 1A). Meses después el paciente acudió nuevamente por persistencia y reagudización de la clínica, la cual no cedía con analgésicos simples. Ante este hallazgo se repitió la tomografía craneal que evidenció persistencia la ocupación etmoidal, en esta ocasión acompañada de osteólisis de las celdillas (foto 1B). Estos hallazgos y los antecedentes del paciente sugirieron el diagnóstico de sinusitis fúngica invasiva crónica. Se amplió el estudio con la realización de RM craneal, en la que se observó extensión de la lesión hacia la grasa extraconal de la órbita derecha