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INTRODUCTION: Stereotactic radiosurgery (SRS) is a minimally invasive option commissioned in the treatment of intracranial arteriovenous malformations (AVMs). As long-term follow-up data became available, some late adverse effects have been reported, including SRS-induced neoplasia. However, the exact incidence of this adverse effect is unknown. In this article we present and discuss the topic with an unusual case of a young patient who was treated with SRS for AVM and developed a malignant brain tumor.
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Glioblastoma , Malformações Arteriovenosas Intracranianas , Radiocirurgia , Humanos , Seguimentos , Resultado do Tratamento , Glioblastoma/etiologia , Glioblastoma/cirurgia , Radiocirurgia/efeitos adversos , Estudos Retrospectivos , Malformações Arteriovenosas Intracranianas/cirurgia , Malformações Arteriovenosas Intracranianas/etiologiaRESUMO
Background: Drug-coated balloons (DCB) are an established tool in the prevention and treatment of coronary and peripheral artery restenosis. The underlying effects of restenosis resemble those in the neurovascular field, yet data on the use of DCB in cervical and intracranial arteries is rare. Methods: Medline, and international and major national guidelines and recommendations were systematically searched for data addressing the use of DCB in the neurovascular setting. Results: Of the 1448 relevant records found in Medline, 166 publications were considered for this review. Conclusions: Data on the use of DCB in the neurovascular setting show a possible benefit over preceding alternatives, such as self-expanding stents, and balloon-mounted or drug-eluting stents. Nonetheless, the role of DCB remains under-researched, and publications remain lacking.
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In 2015, mechanical thrombectomy (MT) in combination with intravenous thrombolysis was demonstrated to be superior to best medical treatment alone in patients with anterior circulation stroke. This finding resulted in an unprecedented boost in endovascular stroke therapy, and MT became widely available. MT was initially approved for patients presenting with large vessel occlusion in the anterior circulation (intracranial internal carotid artery or proximal middle cerebral artery) within a 6-hour time window. Eventually, it was shown to be beneficial in a broader group of patients, including those without known symptom-onset, wake-up stroke, or patients with posterior circulation stroke. Technical developments and the implementation of novel thrombectomy devices further facilitated endovascular recanalization for acute ischemic stroke. However, some aspects remain controversial. Is MT suitable for medium or very distal vessel occlusions? Should emergency stenting be performed for symptomatic stenosis or recurrent occlusion? How should patients with large vessel occlusion without disabling symptoms be treated? Do certain patients benefit from MT without intravenous thrombolysis? In the era of personalized decision-making, some of these questions require an individualized approach based on comorbidities, imaging criteria, and the severity or duration of symptoms. Despite its successful development in the past decade, endovascular stroke therapy will remain a challenging and fascinating field in the years to come. This review aims to provide an overview of patient selection, and the indications for and execution of MT in patients with acute ischemic stroke.
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BACKGROUND: Hemangioblastomas (HGBs) are highly vascular benign tumors, commonly located in the posterior fossa, and 80% of them are sporadic. Patients usually present with features of raised intracranial pressure and cerebellar symptoms. HGB can be classified as either mostly cystic or solids. Although the solid component is highly vascularized, aneurysm or hemorrhagic presentation is rarely described, having catastrophic results. METHODS: We identified 32 consecutive patients with posterior fossa HBG who underwent surgery from 2008 through 2020 at our medical center. Tumors were classified as predominantly cystic or solid according to radiological features. Resection was defined as gross total (GTR) or subtotal (STR). RESULTS: During the study period, 32 posterior fossa HGBs were resected. There were 26 cerebellar lesions and 4 medullar lesions, and in 2 patients, both structures were affected. Predominant cystic tumors were seen in 15 patients and solids in 17. Preoperative digital subtraction angiography (DSA) was performed in 8 patients with solid tumors, and 4 showed tumor-related aneurysms. Embolization of the tumors was performed in 6 patients, including the four tumor-related aneurysms. GTR was achieved in 29 tumors (91%), and subtotal resection in 3 (9%). Three patients had postoperative lower cranial nerve palsy. Functional status was stable in 5 patients (16%), improved in 24 (75%), and 3 patients (9%) deteriorated. One patient died 2 months after the surgery. Two tumors recurred and underwent a second surgery achieving GTR. The mean follow-up was 42.7 months (SD ± 51.0 months). CONCLUSIONS: Predominant cystic HGB is usually easily treated as the surgery is straightforward. Those with a solid predominance present a more complex challenge sharing features similar to arteriovenous malformations. Given the important vascular association of solid predominance HGB with these added risk factors, the preoperative assessment should include DSA, as in arteriovenous malformations, and endovascular intervention should be considered before surgery.
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Malformações Arteriovenosas , Neoplasias Cerebelares , Hemangioblastoma , Doença de von Hippel-Lindau , Neoplasias Cerebelares/diagnóstico por imagem , Neoplasias Cerebelares/cirurgia , Hemangioblastoma/diagnóstico por imagem , Hemangioblastoma/cirurgia , Humanos , Recidiva Local de Neoplasia/patologia , Estudos Retrospectivos , Resultado do Tratamento , Doença de von Hippel-Lindau/complicaçõesRESUMO
OBJECTIVES: Cerebral sinus venous thrombosis (CSVT) is a rare stroke subtype that is more common in women, yet data regarding sex-specific characteristics are sparse. We aimed to study male-specific characteristics among patients with CSVT. MATERIALS & METHODS: Data of consecutive patients with CSVT, admitted to a single medical centre between 2005 and 2020, were retrospectively studied. Demographics, clinical presentations, radiological and outcome parameters were compared between male and female patients. Male patients were further divided into older and younger than 35 years old for additional comparisons. RESULTS: Out of 15,224 patients diagnosed with stroke, 150 patients (1%) presented with CSVT and 47 (31.3%) of them were males. Males had significantly higher rates of previous thrombotic events (22% vs. 7%, p = .009), malignancies (32% vs. 16%, p = .022) and Behcet's disease (22% vs. 2%, p < .001). Additionally, we found that malignancies were significantly more prevalent in older males (48% vs. 17%, p = .022), while Behcet's disease was more often found in younger patients (35% vs. 9%, p = .032). Additional age-related differences in disease characteristics among male patients included a higher frequencies of papilledema (42% vs. 13%, p = .028), and cortical vein thromboses (21% vs. 0% p = .021) observed in the younger men. CONCLUSIONS: There are important differences in risk factors for thrombosis between men and women with CSVT. Behcet's disease is common in younger men, while malignancies are major causes of CSVT in older men.
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Síndrome de Behçet , Trombose dos Seios Intracranianos , Trombose Venosa , Idoso , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Trombose dos Seios Intracranianos/diagnóstico por imagem , Trombose dos Seios Intracranianos/epidemiologia , Trombose Venosa/epidemiologiaRESUMO
PURPOSE: Infarct growth and final infarct volume are established outcome modifiers following endovascular thrombectomy (EVT) for patients with large vessel occlusion stroke (LVO). Simple techniques for final infarct volume measurement are lacking, and therefore, we tested whether post-EVT ASPECTS can be used for prognostic evaluation after EVT. METHODS: Infarct size at baseline was measured in a prospective cohort of patients with LVO that underwent EVT with the ASPECTS score on admission non-contrast CT. Final infarct size was assessed with a post-EVT ASPECTS (ASPECTS-POST) obtained from a follow-up CT 24-72 h post-EVT. The best performing ASPECTS-POST was chosen based on comparisons of different thresholds. Outcome measures included survival rates and modified Rankin Score at 90 days. RESULTS: A total of 272 patients were included and 166 of them had an ASPECTS-POST ≥ 7. ASPECTS-POST ≥ 7 was associated with increased likelihood of favorable outcome at 90 days (67% vs. 21%, p < 0.001) with sensitivity, specificity, and positive and negative predictive values of 86%, 58%, 61%, and 85%, respectively. On multivariate analysis, ASPECTS-POST ≥ 7 was found to be a significant modifier of favorable outcome (Odds Ratio [OR] 6.2, 95% confidence intervals [CI] 3.1-12.4) and survival (OR 5.8 95% CI 2.4-14.3). CONCLUSION: ASPECTS can be rapidly and easily obtained from the post-EVT NCCT and ASPECTS-POST ≥ 7 correlates with good outcome.
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Procedimentos Endovasculares , Acidente Vascular Cerebral , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVES: Endovascular thrombectomy (EVT) is efficacious in patients with large vessel occlusion stroke (LVO). We explored whether internal carotid (ICA) tortuosity increases the technical difficulty of EVT thereby lowering the chances of successful recanalization and favorable outcomes. PATIENTS AND METHODS: Consecutive patients with LVO and patent ICAs who underwent EVT were included. Carotid tortuosity was determined on pre-EVT CTA and classified by raters blinded to outcomes into: type 1-straight ICA trunk and type 2-severe tortuosity potentially impeding adequate catheter placement. Thrombolysis in cerebral infarction (TICI) 2b-3 was considered successful recanalization, and 90-day-modified Rankin Scale ≤ 2 was considered favorable functional outcome. RESULTS: Among 302 patients (mean age 70 ± 15, median NIHSS 17), 53% had type 1, and 47% type 2 tortuosity. Overall, 85% had successful recanalization. Patients with type 2 tortuosity were significantly older (p < 0.0001) and less frequently achieved successful recanalization (80% vs. 90%; p = 0.019) but had similar outcomes compared with those without tortuosity. On regression analysis, marked tortuosity was associated with lower chances of successful recanalization (OR 0.43 95% CI 0.20-0.92) but had no effect on clinical outcomes. CONCLUSIONS: Carotid tortuosity does not appear to impact the likelihood of favorable functional outcome but may influence recanalization.
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Procedimentos Endovasculares , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Infarto Cerebral , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia , Resultado do TratamentoRESUMO
BACKGROUND: Superficial temporal artery-middle cerebral artery microvascular bypass (STA-MCA MVB) is an important strategy for the management of selected patients OBJECTIVES: To present our 19-year experience with STA-MCA MVB METHODS: Data for consecutive patients who underwent STA-MCA MVB from 20002019 due to moyamoya/moyamoya-like disease, complex intracranial aneurysms, or intractable brain ischemia due to internal carotid artery or MCA occlusive disease with repeated ischemic events were retrospectively analyzed under a waiver of informed consent. Key surgical steps and the important role of neuroendovascular interventions are presented. Surgical results and late outcomes were analyzed RESULTS: The study included 32 patients (17 women [53%], 15 men [47%]), mean age 42.94 years (range 1666). The patients underwent 37 STA-MCA MVB procedures during the study period: 22 with moyamoya/moyamoya-like disease (69%) underwent 27 surgeries (five bilateral); 7 patients with complex aneurysms (22%) and 3 patients with vascular occlusive disease (9%) underwent unilateral bypass. Five of seven aneurysms were treated with coiling or flow-diverter stent implant prior to bypass surgery; two were clipped during the bypass procedure. There were no surgical complications, no perioperative mortality, and no death from complications related to neurovascular disease at late follow-up. Transient neurological deficits following 7/37 surgeries (19%) resolved with no permanent neurologic sequelae. Transient ischemic attacks occurred only in the immediate postoperative period in four patients (11%) CONCLUSIONS: In specific cases, STA-MCA MVB is a feasible and clinically effective procedure. It is important to preserve this technique in the surgical armamentarium
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Arteriopatias Oclusivas/cirurgia , Isquemia Encefálica/cirurgia , Aneurisma Intracraniano/cirurgia , Doença de Moyamoya/cirurgia , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/cirurgia , Estudos Retrospectivos , Artérias Temporais/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND AND PURPOSES: Stroke secondary to emergent large vessel occlusions (ELVO) involving the anterior circulation can be treated with intravenous tissue plasminogen activator (IV-tPA) or thrombectomy. Data regarding the influence of the number of stentriever passes needed for vessel recanalization on outcome is lacking. PATIENTS AND METHODS: We prospectively accrued data on consecutive patients with ELVO that were treated with thrombectomy. Procedural details including the number of stentriever passes needed to achieve vessel recanalization and clot length were collected. Functional outcome was determined with the modified Rankin Scale (mRS) at 90 days post stroke with mRS ≤ 2 considered favorable outcome. Data on demographics, risk factors, stroke severity, survival, and occurrence of symptomatic intracranial hemorrhage (sICH) was also collected. RESULTS: On univariate analysis more than one pass needed to achieve recanalization impacted survival and functional outcome after 90 days as did age, stroke severity and collateral and reperfusion status. On multivariate logistic regression the number of passes needed to achieve revascularization (OR: 10.0, 95% CI: 2.28-43.94, P = 0.002), age (OR: 0.90, 95% CI: 0.84-0.96, P = 0.001) and collateral status (OR: 7.90, 95% CI: 1.87-33.35, P = 0.005) remained significant modifiers for favorable outcome. On logistic regression the only variable associated with the need to perform more than a single stentriever pass was time from symptom onset to target vessel recanalization (OR: 1.007, 95% CI: 1.002-1.012). CONCLUSIONS: The number of passes needed to achieve target vessel recanalization modifies outcome after thrombectomy and successful recanalization after a single pass is associated with favorable outcome.
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Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Isquemia Encefálica/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Stents , Acidente Vascular Cerebral/complicações , Resultado do TratamentoRESUMO
INTRODUCTION: Most studies evaluating endovascular therapy (EVT) for stroke only included patients without pre-existing disabilities. However, in real life many patients have pre-existing disabilities, and whether they can benefit from EVT remains unknown. METHODS: Patients with emergent large vessel occlusions undergoing EVT were prospectively enrolled. Patients with no or mild pre-existing disabilities (modified Rankin Scale [mRS], 0-2) were compared with patients presenting with pre-existing moderate disability (mRS ≥ 3). Baseline demographics and risk factors, stroke severity (studied with the National Institutes of Health Stroke Scale [NIHSS]), imaging data including pretreatment Alberta Stroke Program Early Computerized Tomography Score (ASPECTS) and ASPECTS collateral scores, as well as procedure-related variables were accrued. Unfavorable outcome was defined as mRS ≥ 4 at day 90. RESULTS: Of 131 enrolled patients, 108 had a baseline mRS of 2 or lower, and 23 had a prestroke mRS score of 3 or higher. Patients with pre-existing mRS scores of 3 or higher were significantly older (80.3 ± 10 versus 66.9 ± 13.7; P = .001) and more often had previous strokes (39% versus 16%; P = .02). Patients with mRS scores of 3 or higher were more likely to have poor outcomes or death (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.3-15.0). Of the 23 patients with pre-existing moderate disability, 8 (35%) maintained their previous degree of disability. On multivariate analysis, age (OR, .92; 95% CI, .88-.97; P = .001), admission NIHSS (OR, .92; 95% CI, .85-.99; P = .042) and pretreatment ASPECTS (OR, 6.4; 95% CI, 1.4-29.5; P = .017) remained significant modifiers of favorable outcome. DISCUSSION AND CONCLUSIONS: Patients with pre-existing moderate disabilities have higher chances of sustaining unfavorable outcomes despite EVT. Nevertheless, some patients maintain the same level of moderate disabilities, and therefore, patients with pre-existing moderate disabilities should not be excluded from EVT.
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Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral/métodos , Distribuição de Qui-Quadrado , Angiografia por Tomografia Computadorizada , Feminino , Nível de Saúde , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Galenic dural arteriovenous fistulas (DAVF) are rare; however, they are the most frequent type of DAVF to manifest aggressive clinical behavior and usually represent a diagnostic and therapeutic challenge for clinicians. METHODS: We retrospectively reviewed clinical and imaging data of patients managed with neuroendovascular techniques for the treatment of galenic DAVFs from 2000 to 2016. We searched the 2000-2016 English-language literature for papers discussing neuroendovascular management of galenic DAVFs, with or without companion surgical procedures. RESULTS: Five patients were treated for galenic DAVFs during the study period (four males; mean age, 61 years). Three presented with progressive neurological deterioration due to venous congestion, two with acute intracranial hemorrhage. Three were treated by staged transarterial embolization procedures (three procedures in two, four procedures in one); two underwent a single transvenous embolization procedure. Four out of five fistulas were completely occluded. All patients improved clinically; the patient whose fistula was partially occluded remains angiographically stable at 2-year follow-up. Six reports describing 17 patients are reviewed. Embolization was performed via transvenous approach in 1/17 and transarterial approach in 16/17 with additional open surgery in 9/16. The trend toward the use of transarterial approaches is based primarily on advances on embolization techniques that allow better and more controllable penetration of the embolizing agents with improved clinical and angiographic results, as well as the technical complexity of the transvenous approach. CONCLUSIONS: Although transarterial embolization is the preferred endovascular route for the management of most galenic DAVFs, selected cases can be successfully treated by transvenous approach.
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Malformações Vasculares do Sistema Nervoso Central/terapia , Angiografia Cerebral , Embolização Terapêutica/métodos , Adulto , Idoso , Malformações Vasculares do Sistema Nervoso Central/complicações , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Embolização Terapêutica/efeitos adversos , Feminino , Humanos , Hiperemia/complicações , Hiperemia/diagnóstico por imagem , Hiperemia/terapia , Hemorragias Intracranianas/complicações , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/terapia , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: We aimed to determine whether bridging provides additional benefits over primary stentriever-based endovascular reperfusion (SER) in patients with proximal middle cerebral artery (pMCA) strokes. METHODS: Clinical and radiologic data from consecutive stroke patients with large anterior circulation infarcts involving the pMCA were analyzed. Stroke subtypes were categorized according to Trial of ORG 10172 in Acute Stroke Treatment criteria. Neurologic deficits were assessed with the National Institutes of Health Stroke Scale (NIHSS), and vessel recanalization was determined using the Thrombolysis in Cerebral Infarction scale at the end of SER. Good outcome was defined as a modified Rankin Scale (mRS) score of 2 or lesser. RESULTS: Fifty-seven patients with a median age of 66 years were included. Of those, 24 received prior systemic tissue plasminogen activator and 33 received primary SER. Atrial fibrillation was more common in patients who underwent SER but there were no other between-group differences in baseline variables, procedure-related variables, or outcome parameters. Six patients died and 27 patients achieved an mRS of 2 or less at 90 days. Patients who were treated with tPA before SER needed less stentriever passes to recanalize the occluded vessel, but bridging did not impact the chances for either survival or favorable outcome. Age (odds ratio [OR], .92; 95% confidence interval [CI], .85-.98) and NIHSS score (OR, .12; 95% CI, .02-.78) were the only variables associated with outcome on multivariate analysis. CONCLUSIONS: Primary SER and bridging resulted in equally high survival and good outcome rates. Our results suggest that the benefits of primary SER in such critically ill patients may bypass the need for bridging therapy and merit further study.
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Isquemia Encefálica/terapia , Procedimentos Endovasculares , Stents , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/cirurgia , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/cirurgia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Noncontrast computed tomography (NCCT) is the gold standard to detect intracerebral hemorrhage (ICH) and ischemic stroke (IS) in patients presenting with acute focal syndromes. Diffusion-weighted magnetic resonance imaging (DW-MRI) obtained at b1000 is highly sensitive to identify acute IS but its sensitivity and specificity to detect ICH has not been systematically studied. METHODS: Patients with a diagnosis of ICH on NCCT were prospectively enrolled and underwent DW-MRI at b1000. Patients with suspected ischemia and a negative NCCT served as controls. All diffusion-weighted imaging (DWI) scans were evaluated blindly by 4 experienced raters. Sensitivity, specificity, and inter-rater variability of the DWI b1000 scans for detection of ICH were determined. RESULTS: In this preliminary pilot study, 15 patients with ICH and 17 patients with IS were included. All ICH lesions seen on NCCT showed a typical pattern on DW-MRI at b1000 with a hypointense core surrounded by a hyperintense rim. ICH volumes and size were similar on NCCT and MRI. All cases of IS were identified on the DWI scans but none were apparent on NCCT. The mean sensitivity and specificity of DW-MRI at b1000 for ICH were 94% and 93.5%, respectively, and the inter-rater variability for ICH detection on DWI was excellent (κ = .84). CONCLUSIONS: DW-MRI at b1000 has a diagnostic yield similar to NCCT for detecting ICH and superior to NCCT for detecting IS. Therefore, DW-MRI may be considered as the initial screening tool for imaging patients presenting with focal neurologic symptoms suggestive of stroke.
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Hemorragia Cerebral/diagnóstico , Imagem de Difusão por Ressonância Magnética/métodos , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/patologia , Hemorragia Cerebral/patologia , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Projetos Piloto , Reprodutibilidade dos Testes , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/patologia , Tomografia Computadorizada por Raios XRESUMO
(1) Background: Cervical arterial dissections (CeAD) are a common cause of stroke in young adults. CeAD can be spontaneous (sCeAD) or traumatic (tCeAD). Whether CeAD subtypes differ in clinical, radiological, and outcome characteristics remains unexplored. (2) Methods: Patients with CeAD were identified and divided between sCeAD and tCeAD. Demographics, clinical features, risk factors, imaging findings, treatments, and outcomes were compared between the groups. Logistic regressions were used to determine characteristics associated with favorable outcome. (3) Results: Overall, 154 patients were included (106 sCeAD and 48 tCeAD). Patients with sCeAD were significantly older (mean ± SD 46 ± 12 vs. 35 ± 14, p < 0.001) and were more likely to have hyperlipidemia (19% vs. 4%, p = 0.016), but other risk factors did not differ. Patients with tCeAD less often had signs of early infarction on imaging (21% vs. 49%, p = 0.001) and had lower stroke severity on admission (NIHSS, median, interquartile range [IQR] 0 (0-9) vs. 2 (0-4), p = 0.012), but more often had symptomatic intracranial hemorrhages (12.5% vs. 2%, p = 0.006). Patients with tCeAD less often had favorable outcomes at 90 days (78% vs. 97%, p < 0.001). In the regression analysis, the only variables associated with favorable outcome were age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.03-1.24), initial stroke severity (OR 0.84, 95% CI 0.73-0.97), degree of vessel stenosis (OR 0.35, 95% CI 0.14-0.83), and involvement of multiple vessels on presentation (OR 0.04, 95% CI 0.02-0.70), whereas dissection subtype was not associated (OR 0.45, 95% CI 0.03-68.80). (4) Conclusions: Dissection subtype is not an independent modifier of the chances of attaining functional independence.
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BACKGROUND: This study reports a multicenter experience of using hydrophilic polymer-coated (HPC) flow diverters with prasugrel single antiplatelet therapy to treat ruptured aneurysms with subarachnoid hemorrhage (SAH). METHODS: Patients treated for intracranial aneurysms within 30 days after SAH with a p64/p48 MW HPC flow diverter were prospectively identified. Clinical presentation and outcomes, periprocedural and postprocedural complications, and degree of occlusion at follow-up were evaluated. RESULTS: A total of 84 patients were treated in 88 sessions (54.5% women; mean age 53.3 years). Four patients (4.7%) experienced flow diverter-dependent complications. No cases of aneurysm re-rupture or hemorrhagic complications related to antiplatelet therapy were recorded. Immediate complete occlusion was achieved in 27.4% of cases (23/84). The rate of complete occlusion among survivors was 83% in early follow-up, 90.2% in mid-term follow-up, and 92.3% in the latest possible follow-up. CONCLUSION: p64/p48 MW HPC flow diverters with prasugrel single antiplatelet therapy were associated with safety from aneurysm re-rupture and high occlusion rates at medium- and long-term follow-up in managing ruptured aneurysms. Adequate management of single antiplatelet therapy with prasugrel is crucial, particularly with higher doses than usual, to avoid both ischemic and hemorrhagic complications.
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BACKGROUND: The mechanism responsible for stroke in patients with embolic stroke of unknown source (ESUS) often remains unknown despite extensive investigations. We aimed to test whether high-resolution intracranial vessel wall MR imaging (icVWI) can add to the diagnostic yield in these patients. PATIENTS AND METHODS: Patients with ESUS were prospectively included into an ongoing registry. Patients that underwent icVWI as part of their diagnostic workup were compared to those that did not have an icVWI. Patients with icVWI positive for intracranial vulnerable plaques were than compared to those without evidence of plaque vulnerability on VWI. RESULTS: A total of 179 patients with ESUS were included and 48 of them (27%) underwent icVWI. Patients that had an icVWI scan were significantly younger, had lower rates of ischemic heart disease and prior disability as well as significantly lower stroke severity. On regression analysis the only factor that remained associated with not obtaining an icVWI scan was increasing age (Odds ratio [OR] 0.97/year, 95% confidence intervals [CI] 0.95-0.97). Among patients that had an icVWI scan 28 (58%) had evidence of plaque enhancement on VWI in the same distribution of the stroke and the remaining 20 studies were negative. The relative proportion of stroke presumed to be secondary to intracranial non-stenotic atheromatous disease increased from 15% in patients without icVWI scans to 58% among patients with icVWI scans (p = 0.001). On regression analysis the only factor that was associated with vulnerable plaques on icVWI was smoking (OR 11.05 95% CI 1.88-65.17). CONCLUSIONS: icVWI can add significant information relevant to stroke pathogenesis and treatment in patients with ESUS and a negative initial exhaustive diagnostic workup.
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AVC Embólico , Placa Aterosclerótica , Acidente Vascular Cerebral , Humanos , AVC Embólico/complicações , Imageamento por Ressonância Magnética , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/complicações , Placa Aterosclerótica/complicações , Placa Aterosclerótica/diagnóstico por imagem , CabeçaRESUMO
Background Cancer is associated with an increased risk of acute ischemic stroke, including large vessel occlusions. Whether cancer status affects outcomes in patients with large vessel occlusions that undergo endovascular thrombectomy remains unknown. Methods and Results All consecutive patients undergoing endovascular thrombectomy for large vessel occlusions were recruited into a prospective ongoing multicenter database, and the data were retrospectively analyzed. Patients with active cancer were compared with patients with cancer in remission. Association of cancer status with 90-day functional outcome and mortality were calculated in multivariable analyses. We identified 154 patients with cancer and large vessel occlusions that underwent endovascular thrombectomy (mean age, 74±11; 43% men; median National Institutes of Health Stroke Scale 15). Of the included patients, 70 (46%) had a remote history of cancer or cancer in remission, and 84 (54%) had active disease. Outcome data at 90 days poststroke were available for 138 patients (90%) and was classified as favorable in 53 (38%). Patients with active cancer were younger and more often smoked but did not significantly differ from those without malignancy in other risk factors, stroke severity, stroke subtype, or procedural variables. Favorable outcome rates among patients with active cancer did not significantly differ compared with those seen in patients without active cancer, but mortality rates were significantly higher among patients with active cancer on univariate and multivariable analyses. Conclusions Our study suggests that endovascular thrombectomy is safe and efficacious in patients with history of malignancy as well as in those with active cancer at the time of stroke onset, although mortality rates are higher among patients with active cancer.
Assuntos
Arteriopatias Oclusivas , Isquemia Encefálica , Procedimentos Endovasculares , AVC Isquêmico , Neoplasias , Acidente Vascular Cerebral , Lesões do Sistema Vascular , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Feminino , Isquemia Encefálica/etiologia , AVC Isquêmico/etiologia , AVC Isquêmico/complicações , Estudos Retrospectivos , Estudos Prospectivos , Resultado do Tratamento , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/complicações , Trombectomia/efeitos adversos , Trombectomia/métodos , Lesões do Sistema Vascular/etiologia , Neoplasias/complicações , Neoplasias/epidemiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodosRESUMO
(1) Background: The mechanism responsible for stroke in patients younger than 50 often remains unknown. This study was designed to assess whether high-resolution intracranial vessel wall MR imaging (icVWI) may be instrumental in determining stroke cause. (2) Methods: Young stroke patients with and without an identified cause of stroke despite an exhaustive investigation were prospectively included. Patients who underwent icVWI were compared to those who did not. We next compared patients with and without intracranial vulnerable plaques on icVWI. (3) Results: Overall, 47 young stroke patients were identified over the span of 2 years and included in this study. Of those, 20 (42%) underwent intracranial icVWI. Cancer prevalence was higher among patients who did not have an icVWI study (19% vs. 0% p = 0.042) but there were no other significant differences between patients who had an icVWI study and those who did not have an icVWI. Among patients who had an icVWI, 11 (55%) had vulnerable plaques and the remaining nine studies were negative. Patients with positive icVWI scans had significantly higher stroke severity at admission (mean ± SD NIHSS score 5.5 ± 3.5 vs. 1.7 ± 2.3, p = 0.012). Patients with positive icVWI scans were more often treated with antiplatelets upon discharge (100% vs. 67%, p = 0.038). (4) Conclusions: icVWI can add significant information relevant to stroke pathogenesis and secondary prevention among young stroke patients with a negative exhaustive diagnostic workup.
RESUMO
BACKGROUND: Due to its high efficacy, flow diversion is increasingly used in the management of unruptured and recanalized aneurysms. Because of the need for perioperative dual antiplatelet treatment (DAPT), flow diversion is not indicated for the treatment of ruptured aneurysms. To overcome this major limitation, surface modification-'coating'-of flow diverters has been developed to reduce platelet aggregation on the implanted device, reduce thromboembolic complications, and facilitate the use of coated flow diverter treatment in patients with single antiplatelet treatment (SAPT). COATING (Coating to Optimize Aneurysm Treatment in the New Flow Diverter Generation) is a prospective, randomized, multicenter trial that aims to determine whether the use of the coated flow diverter p64 MW HPC under SAPT is non-inferior (or even superior) to the use of the bare flow diverter p64 MW under DAPT in relation to thromboembolic and hemorrhagic complications. METHODS: Patients with unruptured or recanalized aneurysms for which endovascular treatment with a flow diverter is indicated will be enrolled and randomly assigned on a 1:1 ratio to one of two treatment groups: p64 MW HPC with SAPT or p64 MW with DAPT. RESULTS: The primary endpoint is the number of diffusion-weighted imaging lesions visualized via MRI assessed within 48 hours (±24 hours) of the index procedure. Secondary primary endpoints are comparing safety and efficacy in both arms. CONCLUSIONS: This randomized controlled trial is the first to directly compare safety and efficacy of coated flow diverters under SAPT with bare flow diverters under DAPT. TRIAL REGISTRATION NUMBER: http://clinicaltrials.gov/ - NCT04870047.