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1.
Mayo Clin Proc ; 95(7): 1512-1529, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32622453

RESUMO

In this comprehensive contemporary review of acute ischemic stroke management, what is new and different will be highlighted beginning with prehospital stroke systems of care, emergency medical systems, and mobile stroke units, followed by hospital stroke teams, emergency evaluation, telemedicine, and brain and vascular imaging, and finishing with emergency treatments including thrombolysis and mechanical thrombectomy.

2.
J Neurointerv Surg ; 2020 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-32601260

RESUMO

BACKGROUND: The prevalence of pial arterial supply to cranial dural arteriovenous fistulas (dAVF) and its implication in the management of these fistulas is not well characterized. We performed a retrospective study to characterize pial arterial supply to dural arteriovenous fistulas and the implications for treatment. METHODS: Consecutive patients evaluated over a 12-year period were retrospectively reviewed. Angiograms were reviewed to characterize dAVF angioarchitecture and the presence of pial artery supply. Pial artery supply was categorized as dilated pre-existing dural branches and pure pial supply. We then studied the association between pial artery supply and clinical, angiographic, and treatment features. RESULTS: A total of 201 patients were included of which 27 (13.4%) had pial artery supply. Of these, 11 had supply from dilated pre-existing dural branches, nine had pure pial supply,and seven had both. There was a higher rate of dAVF rupture in the pial supply group (30.8% vs 9.8%, P=0.003) and these fistulas had a higher rate of Borden 2 and 3 (88.9% vs 38.4%, P<0.0001). Fistulas with pial artery supply had similar rates of endovascular and gamma knife treatment, but were more likely to undergo surgery than those without pial supply (25.9% vs 10.4%, P=0.03). Major complication rates were similar between groups (0% vs 1.1%, P=0.55). CONCLUSIONS: More than 10% of dAVFs also have pial supply but this is not a contraindication to embolization. In our study pure pial supply was associated with a more aggressive fistula and was most common in tentorial dAVFs.

3.
Expert Rev Med Devices ; 17(6): 519-532, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32500761

RESUMO

INTRODUCTION: Stent-assisted coiling (SAC) of intracranial aneurysms paved the way for endovascular coiling of wide-neck and bifurcation aneurysms, improving rates of aneurysm obliteration and recurrence. In this review, we provide a comprehensive review of the most recent advances related to stent-assisted coiling of intracranial aneurysm. AREAS COVERED: The authors have made an attempt to cover the inception, applications, and limitations of SAC of intracranial aneurysms. Special focus is given to 1) the current and recently introduced SAC techniques, 2) most recent advances in device technology, and 3) outcome data for the discussed techniques and devices. The authors also discuss the potential future direction of SAC. EXPERT OPINION: technical refinements in the field of SAC should continue to focus on device development and addressing the limitations of SAC, namely aneurysm recurrence and need of antiplatelet agents. Although the recurrence rate of SAC has not been shown to be inferior to flow diverters, the use of intrasaccular and intravascular flow diverters are likely to expand in the future at the expense of SAC.

5.
World Neurosurg ; 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32540292

RESUMO

We describe evolution of a DVA over time in a patient with a complex intracranial vascular malformation. A 26 year-old male initially presented with a scalp vascular malformation and was later diagnosed to have a torcular dural arteriovenous fistula resembling a dural sinus malformation. The dural fistula increased in size over four years. The dural fistula was also associated with multiple complex developmental venous anomalies draining the bilateral cerebral hemispheres and cerebellum. The DVAs was only faintly demonstrated on the baseline MRI but appeared to increase in size and extent over time as the dural arteriovenous fistula developed more aggressive angioarchitecture features. In addition to the evolution manifestation of the DVAs, the patient developed multiple de novo cavernous malformations in the venous radicles of the DVA. Increased venous hypertension in the superficial venous system from the dural fistula likely resulted in growth of the DVAs as they served as the primary means of venous drainage for the bilateral cerebral hemispheres. The patient also had re-opening of the persistent falcine sinus which was not present at baseline. This would be the first reported case of growth or evolution of a DVA in association with a dural arteriovenous fistula in an adult patient and highlights the dynamic nature of both the medullary venous and dural venous sinuses of the cerebral venous system, even into adulthood.

6.
J Neuroradiol ; 2020 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-32169468

RESUMO

The common carotid artery (CCA) and extracranial internal carotid artery are subject to a wide variety of non-atheromatous pathologies. These entities are often overshadowed in both research and clinical realms by atherosclerotic disease. Nevertheless, non-atherosclerotic disease of the carotid arteries may have profound, even devastating, neurologic consequences. Hence, this review will cover both common and uncommon forms of extracranial carotid artery pathologies in a pictorial format, in order to aid the diagnostician in identifying and differentiating such pathologies.

8.
Int J Neurosci ; : 1-4, 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32019398

RESUMO

Objective: Intracranial dural arteriovenous fistulas represent pathological connections between dural arteries and dural veins, dural sinuses or meningeal veins in the absence of an intervening capillary bed. They are thought to be acquired secondary to trauma, surgery, sinus thrombosis, venous hypertension or arterial dysplasia. Methods: A 66-year-old Asian female presented with subarachnoid hemorrhage secondary to ruptured 2-mm saccular aneurysm of the left middle cerebral artery associated with fusiform dilatation. It was successfully treated with endovascular coiling. A right frontal external ventricular drain was also placed to treat her hydrocephalus. On post-bleed day 10, she became acutely unresponsive with a fixed and dilated right pupil. Head CT was obtained and revealed an acute right subdural hematoma which was emergently evacuated. Results: No obvious bleeders were identified during surgery. Patient improved and repeat catheter angiography a week later showed a new dural arteriovenous fistula fed by the anterior falcine artery and the middle meningeal artery to a cortical vein draining into the superior sagittal sinus. Conclusion: We hope that the present report will raise awareness to treating physicians to be cognizant of this unusual complication in their differential diagnosis when treating patients with an EVD in place.

9.
J Neurosurg ; : 1-9, 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31731270

RESUMO

OBJECTIVE: The impact of FDA approval of flow-diversion technology for the treatment of supraclinoid internal carotid artery aneurysms and the publication of the Carotid Occlusion Surgery Study, both of which occurred in 2011, on the utilization of extracranial-intracranial (EC-IC) bypasses is not known. METHODS: The National Inpatient Sample (NIS) was queried for hospitalizations for EC-IC bypass performed from 2008 to 2016. Diagnoses of interest included an unruptured intracranial aneurysm (UIA), subarachnoid hemorrhage (SAH), carotid occlusive disease (COD), and moyamoya disease. The authors assessed trends in EC-IC bypass utilization for these diagnoses and the incidence of adverse discharges, defined as discharge to locations other than home, and the rate of mortality. RESULTS: A total of 1640 EC-IC bypass procedures were performed at 558 hospitals during the study period, with 1148 procedures at 448 hospitals performed for a diagnosis of interest. The most frequent surgical indication was moyamoya disease (65.7%, n = 754), followed by COD (23.2%, n = 266), SAH (3.2%, n = 37), and a UIA (7.9%, n = 91). EC-IC bypass utilization for COD decreased from 0.21 per 100 admissions of COD in 2010 to 0.09 per 100 admissions in 2016 (p = 0.023). The frequency of adverse discharges increased during the study period from 22.3% of annual admissions in 2008 to 31.2% in 2016 (p = 0.030) when analysis was limited to procedures performed for a diagnosis of interest. Per volume, the top 5th percentile of hospitals, on average, performed 18.4 procedures (SD 13.2) per hospital during the study period, compared to 1.3 procedures (SD 1.3) that were performed in hospitals within the bottom 95th percentile. The rate of adverse discharges was higher at low-volume institutions when compared to that at high-volume institutions (33.8% vs 28.7%; p = 0.029). Over the study period, the authors noted a trend toward a reduced percentage of total surgical volume performed at high-volume hospitals (p < 0.001). CONCLUSIONS: The authors observed a decrease in the utilization of EC-IC bypass for COD during the study period. An increase in the rate of adverse discharges was also noted, coinciding with more procedures being performed at lower-volume centers.

13.
Stroke ; 50(9): 2428-2432, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31366313

RESUMO

Background and Purpose- Racial and ethnic disparities in the access to mechanical thrombectomy (MT) for treatment of acute ischemic stroke (AIS) secondary to large vessel occlusion have been previously described. The effect of recent randomized trials validating MT as an effective therapy for AIS secondary to large vessel occlusion on such disparities has not been investigated. Methods- Information on admissions for AIS to endovascular centers occurring between January 2016 and September 2018 was obtained from a national database. The number of patients receiving IV-tPA (intravenous tissue-type plasminogen activator) and MT at each institution was determined, and patient demographics were characterized according to age, sex, race/ethnicity, and insurance status. Comparisons of patients who did and did not undergo MT and between patients of different racial and ethnic backgrounds were performed. Demographic variables independently associated with the utilization of MT were identified using multivariate linear regression analysis. Results- There were 206 853 admissions to 173 endovascular centers during the time period of interest. The overall utilization of MT was 8.4%. The utilization of MT for black/Hispanic patients was lower than that among white/non-Hispanic patients (7.0% versus 9.8%; P<0.001). Black/Hispanic patients were also less likely to receive IV-tPA (16.2% versus 20.5%; P<0.001) and to be admitted to the endovascular center after transfer from a different hospital (20.0% versus 30.1%; P<0.001). On multivariate linear regression analysis, increasing institutional proportions of patients with female sex (ß=-0.601; P<0.001), insurance with Medicaid or uninsured status (ß=-0.153; P=0.029), and black/Hispanic race/ethnicity (ß=-0.062; P=0.046) were independently associated with lower institutional utilization of MT. Conclusions- Despite the mainstream acceptance of MT for the treatment of AIS secondary to large vessel occlusion, racial and ethnic disparities in the utilization of MT persist.


Assuntos
Isquemia Encefálica/etnologia , Isquemia Encefálica/cirurgia , Disparidades em Assistência à Saúde/etnologia , Acidente Vascular Cerebral/etnologia , Acidente Vascular Cerebral/cirurgia , Trombectomia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Grupos de Populações Continentais/etnologia , Grupos Étnicos , Feminino , Disparidades em Assistência à Saúde/tendências , Humanos , Masculino , Trombectomia/tendências
14.
Neuroradiol J ; 32(3): 166-172, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30942660

RESUMO

OBJECTIVES: Remote ischemic preconditioning has been proposed as a possible potential treatment for ischemic stroke. However, neuroprotective benefits of the pre-procedural administration of remote ischemic preconditioning have not been investigated in patients undergoing an elective endovascular intracranial aneurysm repair procedure. This study investigated the safety and feasibility of remote ischemic preconditioning in patients with an unruptured intracranial aneurysm who undergo elective endovascular treatment. METHODS: In this single-center prospective study, patients with an unruptured intracranial aneurysm undergoing elective endovascular treatment with flow diverters or coiling were recruited. Patients received three intermittent cycles of 5 minutes arm ischemia followed by reperfusion using manual blood cuff inflation/deflation less than 5 hours prior to endovascular treatment. Patients were monitored and followed up for remote ischemic preconditioning-related adverse events and ischemic brain lesions by diffusion -weighted magnetic resonance imaging within 48 hours following endovascular treatment. RESULTS: A total of seven patients aged 60 ± 5 years with an unruptured intracranial aneurysm successfully completed a total of 21 sessions of remote ischemic preconditioning and the required procedures. Except for two patients who developed skin petechiae over their arms, no other serious procedure-related adverse events were observed as a result of the remote ischemic preconditioning procedure. On follow-up diffusion -weighted magnetic resonance imaging, a total of 19 ischemic brain lesions with a median (interquartile range) volume of 245 (61-466) mm3 were found in four out of seven patients. CONCLUSIONS: The application of remote ischemic preconditioning prior to endovascular intracranial aneurysm repair was well tolerated, safe and clinically feasible. Larger sham-controlled clinical trials are required to determine the safety and efficacy of this therapeutic strategy in mitigating ischemic damage following endovascular treatment of intracranial aneurysms.


Assuntos
Procedimentos Endovasculares , Aneurisma Intracraniano/terapia , Precondicionamento Isquêmico , Angiografia Cerebral , Imagem de Difusão por Ressonância Magnética , Estudos de Viabilidade , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
15.
World Neurosurg ; 127: e1232-e1236, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31009780

RESUMO

BACKGROUND: Flow diversion (FD) has emerged as an effective treatment modality for aneurysms of the posterior communicating artery (PCOM). Whether or not a fetal posterior circulation (FPC) affects PCOM aneurysm occlusion rates after FD remains undetermined. METHODS: We performed a retrospective cohort study in which treatment outcomes for FD of PCOM aneurysms from multiple institutions were reviewed. The primary outcome of interest was complete aneurysm occlusion at last follow-up. The presence of a FPC, defined as a PCOM diameter larger than that of the P1 segment, was noted and its relationship to complete aneurysm occlusion was investigated using a Cox proportional hazards model. RESULTS: There were 49 patients with 49 PCOM aneurysms treated with FD who met inclusion criteria for analysis. A FPC was present in 16 patients (32.7%). Complete aneurysm occlusion was observed in 34 patients (69.4%). Complete occlusion was less common for patients with a FPC (43.7% vs. 81.8%; P = 0.007). For patients with and without a FPC, median time to occlusion was 51 and 6 months, respectively (P = 0.002). Using a multivariable Cox proportional hazards model, a FPC was associated with reduced odds of complete occlusion on last follow-up (risk ratio 0.35, 95% confidence interval 0.14-0.89; P = 0.029). CONCLUSIONS: Our results indicate reduced efficacy of FD for the treatment of PCOM aneurysms associated with a FPC. These findings may influence treatment selection for aneurysms at this location.


Assuntos
Círculo Arterial do Cérebro/diagnóstico por imagem , Círculo Arterial do Cérebro/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Stents Metálicos Autoexpansíveis , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
17.
J Neurointerv Surg ; 11(8): 768-771, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30602486

RESUMO

OBJECTIVE: Relatively little is known about the effect of malignancy on patient outcomes after acute ischemic stroke (AIS) or utilization rates of stroke interventions in this population. We aimed to assess the effect of underlying malignancy on outcomes and treatment of AIS at a population level. METHODS: Outcomes after AIS between patients with and without malignancy were compared using a national database of hospital reported outcomes. RESULTS: There were 351 institutions reporting the outcomes of 3 18 127 admissions for AIS. Of these admissions, 16 141 patients carried a pre-existing diagnosis of malignancy at the time of admission. Administration of intravenous tissue plasminogen activator (IV tPA) was less common in patients with malignancy compared with patients without malignancy (7.3% vs 10.7%; P<0.001) but there was no difference in the rate of mechanical thrombectomy (3.1% vs 3.1%; P=0.967). Mortality rates were higher among patients with malignancy (7.1% vs 3.7%; P<0.001), a relationship which persisted when analysis was restricted to patients receiving IV tPA (10.8% vs 6.1%; P<0.001) or thrombectomy (20.3% vs 13.5%; P<0.001). Rates of both IV tPA administration (2.5% vs 10.5%; P<0.001) and mechanical thrombectomy (2.1% vs 5.4%; P<0.001) were lower in patients with brain malignancy relative to patients with malignancy of non-CNS origin. CONCLUSION: A diagnosis of malignancy on admission for acute stroke was associated with a higher rate of mortality. Malignancy was also associated with a lower rate of IV tPA administration but no difference in mechanical thrombectomy utilization.


Assuntos
Isquemia Encefálica/epidemiologia , Isquemia Encefálica/terapia , Neoplasias/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Bases de Dados Factuais/tendências , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Acidente Vascular Cerebral/diagnóstico
19.
Neurosurg Focus ; 46(Suppl_1): V7, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30611180

RESUMO

Arteriovenous fistulae of the internal maxillary artery are exceedingly rare, with less than 30 cases reported in the literature. Most of these lesions are congenital, iatrogenic, or posttraumatic. The most common presentation of internal maxillary artery fistulae is pulsatile tinnitus and headache. Because these lesions are single-hole fistulae, they can be easily cured with endovascular techniques. The authors present a case of a patient who presented to their institution with a several-year history of pulsatile tinnitus who was found to have an internal maxillary artery arteriovenous fistula, which was treated endovascularly with transarterial coil and Onyx embolization.The video can be found here: https://youtu.be/fDZVMMwpwRc.

20.
J Neurointerv Surg ; 11(8): 833-836, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30674633

RESUMO

BACKGROUND AND PURPOSE: Previous studies have documented disparate access to cerebrovascular neurosurgery for patients of different racial and socioeconomic backgrounds. We further investigated the effect of race and insurance status on access to treatment of unruptured intracranial aneurysms (UIAs) and compared it with data on patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: Through the use of a national database, admissions for clipping or coiling of an UIA and for aSAH were identified. Demographic characteristics of patients were characterized according to age, sex, race/ethnicity, and insurance status, and comparisons between patients admitted for treatment of an UIA versus aSAH were performed. RESULTS: There were 10 545 admissions for clipping or coiling of an UIA and 33 166 admissions for aSAH between October 2014 and July 2018. White/non-Hispanic patients made up a greater proportion of patients presenting for treatment of an UIA than those presenting with aSAH (64.3% vs 48.2%; P<0.001), whereas black/Hispanic patients presented more frequently with aSAH than for treatment of an UIA (29.3% vs 26.1%; P=0.006). On multivariate linear regression analysis, the proportion of patients admitted for management of an UIA relative to those admitted for aSAH increased with the proportion of patients who were women (P<0.001) and decreased with the proportion of patients with a black/Hispanic background (P=0.010) and those insured with Medicaid or without insurance (P=0.003). CONCLUSION: For patients with UIAs, racial, ethnic, and socioeconomic backgrounds appear to continue to influence access to treatment.


Assuntos
Grupos de Populações Continentais/etnologia , Acesso aos Serviços de Saúde/economia , Disparidades em Assistência à Saúde/economia , Aneurisma Intracraniano/economia , Aneurisma Intracraniano/etnologia , Adulto , Idoso , Feminino , Acesso aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Hospitalização/tendências , Humanos , Aneurisma Intracraniano/terapia , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/economia , Procedimentos Neurocirúrgicos/tendências , Resultado do Tratamento , Estados Unidos/etnologia , Adulto Jovem
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