Use of intracranial stent as rescue therapy after mechanical thrombectomy failure-9-year experience in a comprehensive stroke centre.

PURPOSE: There is no established rescue treatment in patients with mechanical thrombectomy (MT) failure. Our aim is to analyse whether the use of an intracranial stent improves prognosis in these patients. METHODS: Retrospective analysis of a prospective cohort of patients with ischemic stroke due to middle cerebral artery occlusion (MCA) or distal intracranial carotid artery (ICA) occlusion, from September 2009 to April 2019 in our comprehensive stroke care centre. Patients with MT failure were identified and dichotomized into two groups according to whether or not an intracranial stent was implanted. We analysed clinical outcomes in both groups. RESULTS: There was MT failure in 60 patients (14%) of the 433 with large vessel occlusion in distal ICA and proximal MCA. A stent was placed in 20 of them (33.3%). Compared to patients without rescue stenting, they showed better rates of independence at 3 months (mRS ≤ 2) 45% vs 2.5% (p < 0.001) and lower mortality 15% vs 50% (p = 0.009), maintaining statistical significance after multivariate analysis, without a significant increase of the rate of symptomatic intracranial haemorrhage (p = 0.209). CONCLUSION: Placement of an intracranial stent as rescue therapy after MT failure was associated with better clinical outcome without significant increase in haemorrhagic complications. We believe that this procedure should be appraised in these patients.

Suboptimal interventional conditions for the occlusion of ruptured intracranial aneurysms do not increase periprocedural complications and poor clinical outcomes.

BACKGROUND AND OBJECTIVE: Occluding a ruptured intracranial aneurysm as early as possible may entail certain periprocedural conditions that compromise the outcome. The aim of the present study was to evaluate the effectiveness, safety, and clinical outcome of endovascular coiling procedures performed on an emergency basis under potentially suboptimal conditions, and to compare results with those from scheduled procedures under potentially optimal conditions. METHODS: Interventions performed on 66 SAH patients were retrospectively analysed by classifying them into two groups: under emergency (within three hours from diagnosis or during non-standard working hours) or scheduled conditions. A binary logistic regression analysis was also performed to identify characteristics associated with poor outcomes. RESULTS: No differences in effectiveness, periprocedural complications, or clinical outcomes were found between the two groups. Rebleeding was detected in 4.8 % of the emergency interventions and 2.2 % of the scheduled interventions. Multivariate analysis identified age and Hunt and Hess grade, but no conditions of treatment, as the factors associated to poor outcome. CONCLUSION: Suboptimal interventional conditions for occluding ruptured intracranial aneurysms, such as performing procedures outside of standard working hours or within three hours of diagnosis, do not result in increased periprocedural complications and poor clinical outcomes compared with scheduled procedures under potentially optimal conditions. These results suggest the need for treatment to be provided as soon as possible.

Combined staged therapy of complex arteriovenous malformations: initial experience.

OBJECTIVES: Definitive treatment of complex supratentorial arteriovenous malformations (AVMs) has been classically assigned to ruptured or progressively symptomatic cases. The aim of this study is to report our initial experience in the treatment of complex AVMs by means of staged embolization with Onyx followed by microsurgery. MATERIAL AND METHODS: Thirteen consecutive patients with supratentorial Spetzler-Martin grades III, IV and V AVMs were treated between January 2009 and June 2010. Mean age at the beginning of the therapy was 34. All patients were symptomatic. Mean AVM size was 48 mm, and mean volume prior to embolization was 47 ml. RESULTS: Mean number of endovascular procedures was 3, and mean volumetric obliteration prior to surgery was 79.2%. Mean time between two embolizations was 24 days. One patient showed a non-disabling complication after endovascular procedures. Mean time between the last embolization and surgery was 42 days. Two patients showed disabling complications after surgery, and one patient showed a non-disabling complication. Follow-up angiography showed the complete removal of permeable AVM in all patients. According to the modified Rankin Scale, all patients were non-dependent concerning daily life activity at 6-month follow-up. One-year follow-up angiography has been performed in 11 patients so far showing an absence of permeable AVM in spite of the remainder intravascular Onyx. CONCLUSIONS: Staged preoperative embolization with Onyx followed by microsurgery has made possible 100% cure of complex AVMs with 0% mortality, 15.4% disabling complications and 15.4% non-disabling complications. Complete Onyx resection is not essential to achieve the cure of the patient.

Cytological changes induced by embolization in meningiomas.

OBJECTIVE: To describe cytological changes in meningiomas induced by embolization, which may be carried out a few days before surgery in order to soften the tumour and minimize intraoperative bleeding. Although histological changes have been described, we have found no description of such changes in the cytological literature. METHODS: We reviewed 22 cases of meningiomas with prior embolization in which cytological material was obtained during intraoperative consultation. In 13 of them recognizable cytological changes induced by embolization were present. On histology, these 13 tumours were grade I and showed intravascular embolic material. RESULTS: Cellular dissociation was prominent, with frequent single cells and small groups. Ischaemic cellular changes were a common finding and consisted of cell shrinkage, nuclear pyknosis and karyorrhexis. Confluent areas of necrosis were seen in one case. Additionally, numerous macrophages were present, many containing cellular debris, and neutrophils, giving a characteristic appearance of acute cellular ischaemia. Embolic material was seen cytologically in four cases as well-defined spherules surrounded by empty halos. Features of viable meningioma were recognized in all cases. CONCLUSION: Embolization of meningiomas induces cytological changes that mirror those seen on histology, but cellular dissociation with changes of ischaemia may result in a worrisome image. When faced with such changes the pathologist should consider the possibility of embolization, avoiding misdiagnosis of higher grade meningioma or metastatic carcinoma.

Radiation Doses in Patient Eye Lenses during Interventional Neuroradiology Procedures.

BACKGROUND AND PURPOSE: Eye lenses are among the most sensitive organs to x-ray radiation and may be considered at risk during neurointerventional radiology procedures. The threshold dose to produce eye lens opacities has been recently reduced to 500 mGy by the International Commission on Radiologic Protection. In this article, the authors investigated the radiation doses delivered to patients' eyes during interventional neuroradiology procedures at a university hospital. MATERIALS AND METHODS: Small optically stimulated luminescence dosimeters were located over patients' eyes during 5 diagnostic and 31 therapeutic procedures performed in a biplane x-ray system. Phantom measurements were also made to determine the level of radiation to the eye during imaging runs with conebeam CT. RESULTS: The left eye (located toward the lateral C-arm x-ray source) received a 4.5 times greater dose than the right one. The average dose during embolization in the left eye was 300 mGy, with a maximum of 2000 mGy in a single procedure. The patient who received this maximum eye dose needed 6 embolization procedures to treat his high-volume AVM. If one took into account those 6 embolizations, the eye dose could be 2-fold. Sixteen percent of the embolizations resulted in eye doses of >500 mGy. CONCLUSIONS: A relevant fraction of patients received eye doses exceeding the threshold of 500 mGy. A careful optimization of the procedures and follow-up of these patients to evaluate potential lens opacities should be considered.

The role of dural anomalies in vein of Galen aneurysms: report of six cases and review of the literature.

It is proposed that the vein of Galen aneurysm represents a venous ectasia secondary to an increased flow (usually caused by a deep-seated arteriovenous shunt draining either directly into the vein of Galen aneurysm or into a tributary of the vein of Galen) associated with obstruction of a dural sinus distal to the aneurysm. The closer the venous obstruction is to the vein of Galen, the better the chances are of developing obstructive (noncommunicating) hydrocephalus and the more likely it is that the venous drainage from the rest of the brain will be unaffected. The farther the venous obstruction is from the vein of Galen aneurysm, the better the chances are of developing a communicating type of hydrocephalus. The development of cardiac failure is related to the magnitude of the arteriovenous shunt. Brain damage, seizures, and hemorrhage may be related to the retrograde venous engorgement, causing impaired drainage of the healthy brain. Careful attention should be paid to the venous drainage characteristics of the lesion because the types of dural venous obstructions and anomalies vary from case to case. The term "vein of Galen aneurysm" should be abandoned in favor of the term "vein of Galen ectasia."

Comparative trial of Hexabrix (320 mg iodine/ml), iohexol (300 mg iodine/ml) and iopamiron (300 mg iodine/ml) in cerebral and spinal angiography: a preliminary report.

A comparison has been carried out of results of cerebral and spinal-cord angiography with two non-ionic contrast media, iohexol and Iopamiron, and a low-osmolality contrast medium, Hexabrix. A comparative study of iohexol, Hexabrix, and Iopamiron was carried out in a first group of 41 patients, and Hexabrix was compared with Iopamiron in a second group of 56. Evaluation criteria included local and general safety, as well as quality of angioscopy and angiography. In the first group of patients there were no significant differences in safety between the three agents. On the other hand, quality of visualisation during angioscopy with Hexabrix was clearly better. In the second group, safety and quality of the radiographic images were identical; however, once again, quality of angioscopy was better with Hexabrix than with Iopamiron. We conclude that Hexabrix appears to be the best opacifying agent currently available for cerebral and spinal-cord angiography. While results with Iopamiron were quite similar, the latter agent is slightly more expensive.

[Images of magnetic resonance and computerized axial tomography in a case of subacute post-myocardial infarct heart rupture]. / Imágenes de resonancia magnética y tomografía axial computadorizada en un caso de rotura cardíaca subaguda postinfarto de miocardio.

In a patient with clinical and hemodynamic criteria of cardiac tamponade, during the acute phase of myocardial infarction, a two dimensional echocardiographic study showed pericardial effusion with an echo-dense mass in the pericardial space. Subacute ventricular free-wall rupture diagnosis was suspected. A cardiac computerized tomography (CT) and magnetic resonance (MR) study was made. CT showed an elevated density (32 HU) of pericardial effusion suggesting hemopericardium. RM imaging showed a very high and homogeneous signal in the pericardial space consistent with a methemoglobin phase clot. Anatomic confirmation was not possible.

[X-ray computed tomography (CT scanner) in schizophrenia. Comparison of its results with other studies]. / Tomodensitométrie (CT scanner) au cours de la schizophrénie. Confrontation de ses résultats avec d'autres investigations.

This paper concerns the tomodensitometric (TDM) study, with the same clinical and radiological criteria, of 78 schizophrenic patients (age: less than 60 years) from psychiatric hospitals in Madrid and from Sainte-Anne hospital (Paris). The length of evolution and the severity of disturbances seemed to be the most important causal elements of cerebral atrophy. Some TDM peculiarities appeared correlated with some clinical forms (paranoid or hebephrenic). The review of previous works illustrates the importance of some etiological conditions for the production of cerebral atrophy: age, length of evolution and, more particularly, the severity of the disease. The confrontation of the anatomo-pathological and pneumoencephalographic studies with the TDM results suggests that, if the TDM is a good indicator of ventricular dilatation, appreciation of the widening of the cerebral sulci remains difficult.

[Vertebral artery loop and cervical pain]. / Boucle de l'artère vertébrale et cervicalgies.

Diagnosis of a vertebral artery loop in the transverse canal, suggested by a CT scan image, is dependent mainly on results of angiography (preferably computer assisted and by the venous route). This lesion is a differential diagnosis of a neuroma, when the cervical intervertebral foramen is enlarged.

[Endovascular treatment of pure spontaneous dural vascular malformations. Review of 23 cases studied and treated between May 1980 and October 1983]. / Traitement endovasculaire des malformations vasculaires durales (MVD) pures "spontanées". Revue de 23 cas explorés et traités entre mai 1980 et octobre 1983.

The authors present 23 cases of pure dural spontaneous vascular malformations (DVM) between 1980 and 1983; among the 23 patients, presented with a sellar DVM, 10 with a torcular DVM and adjacent sinuses, 1 DVM was located at the lamina cribriformis. The history of the patients can be classified into 3 groups: - trauma history (9 patients); - vascular disease (15 patients); - infections history (1 patient). Certain remarkable associations were encountered: 2 cases of multifocal DVM, 3 cases with intracranial aneurysms, 1 case with a brain AVM in an other territory, 1 maxillo-facial AVM. Certain aspects of the symptomatology can be noted: 1 case was in a child of 3 years of age, 2 cases presented during pregnancy, 1 case with premenstrual changes, 2 cases with acute choroidal detachment. Of the 11 patients which had a DVM with cortical venous drainage, 9 were complaining of CNS symptoms and 3 were explored in emergency: 2 for SAH, 1 for acute spontaneous SDH. In this series, following a multidisciplinary decision, the treatment chosen was always endovascular a priori. However it was preceded in one case by surgery at the anterior base of the skull in order to develop a collateral circulation from a reachable artery (for embolization); in an other case, it was followed by surgery to evacuate a compressive SDH, and in an other it was completed by surgery to improve a too proximal embolization. Only once had the internal carotid artery to be occluded to obtain a satisfactory clinical result. One slowly regressive complication was noted following active heparin therapy. No patient has been excluded from this series during that period. With the exception of 1 spontaneous cure, following embolization (s) 13 cases are asymptomatic among which 9 have an anatomical "cure"; 4 cases have an incomplete but significant improvement; 1 patient after a initial good result had recurrent symptoms were stabilized with medical treatment; 2 cases were not embolized for technical reasons, but are asymptomatic. Finally, one died a few days after surgery for evacuation of his SDH. Details of embolic agents and vessels embolized are specified. 5 observations can be made: - The angiographic screening must be complete and must not overlook dangerous vessels which could limit the embolization. - All the vascular compartments of the lesion must be visualized, as all of them do not have to be embolized; the embolic agent has to be radio-opaque and the nidus of the malformation must be reached.(ABSTRACT TRUNCATED AT 400 WORDS)

[Dilatation of the vein of Galen. Anatomoclinical forms and endovascular treatment apropos of 14 cases explored and/or treated between 1983 and 1986]. / Dilatation de la veine de Galien. Formes anatomo-cliniques et traitement endovasculaire à propos de 14 cas explorés et/ou traités entre 1983 et 1986.

The authors report 14 cases of vein of Galen dilatation explored and/or treated between 1983 and 1986. Three anatomic types have been individualized: the vein of Galen arterio-venous malformation (AVM) (7 cases); the cerebral AVM with vein of Galen ectasia (6 cases); the varix of the vein of Galen without AV shunt (1 case). When an AVM is present the shunt is located either in the venous wall (vein of Galen AVM) or in the brain parenchyma; in the latter the AVM drains into a tributary of the vein of Galen (cerebral AVM with vein of Galen ectasia). However in all the 14 cases downstream to the draining vein, a venous (dural) anomaly could be demonstrated. This anomaly suggests the secondary nature of the dilatation proximal to a developmental obstacle. Clinically the vein of Galen AVM reveals early in neonates by cardiac complications; the other types are usually seen later following hydrocephalic or bleeding episodes. As far as therapeutic aspect, we can technically stabilize the hemodynamic problem, by occluding most if not all the shunts by endovascular approach, and make most of the neonates survive. However the quality of survivance and the future neurological development is impossible to predict yet. Nevertheless the short term follow-up is very encouraging. The combined per operative embolization through the vein must be exclusively reserved to vein of Galen AVM. The torcular approach is contraindicated in brain AVM with Vein of Galen ectasia. The vein of Galen varix do not require any type of morphological correction.

Brain radiation doses to patients in an interventional neuroradiology laboratory.

BACKGROUND AND PURPOSE: In 2011, the International Commission on Radiologic Protection established an absorbed-dose threshold to the brain of 0.5 Gy as likely to produce cerebrovascular disease. In this paper, the authors investigated the brain doses delivered to patients during clinical neuroradiology procedures in a university hospital. MATERIALS AND METHODS: The radiation dose delivered to the brain was investigated in 99 diagnostic and therapeutic interventional neuroradiology procedures. Brain doses were calculated in a mathematic model of an adult standard anthropomorphic phantom by using the technical and radiation dose data of an x-ray biplane system submitted to regular quality controls and calibration programs. RESULTS: For cerebral embolizations, brain doses resulted in a maximum value of 1.7 Gy, with an average value of 500 mGy. Median and third quartile resulted in 400 and 856 mGy, respectively. For cerebral angiography, the average dose in the brain was 100 mGy. CONCLUSIONS: This work supports the International Commission on Radiologic Protection recommendation on enhancing optimization when doses to the brain could be higher than 0.5 Gy. Radiation doses should be recorded for all patients and kept as low as reasonably achievable. For pediatric patients and young adults, an individual evaluation of brain doses could be appropriate.

[Endovascular treatment for acute stroke: an open field to begin]. / Tratamiento endovascular del ictus agudo: un campo muy abierto que está por iniciar.

INTRODUCTION: The evidence that recanalization and reperfusion of the distal vascular bed in appropriately selected patients is crucial to achieve good functional outcome has triggered interest and research into endovascular treatment of acute ischemic stroke. DEVELOPMENT: Intravenous (iv) thrombolytic therapy is the treatment of choice in patients with acute ischemic stroke, however, it has certain limitations. Endovascular treatment is a promising alternative with theoretical advantages over iv therapy, such as an increased frequency of recanalization and longer therapeutic windows. Endovascular reperfusion strategies include intra-arterial fibrinolysis with drugs, or endovascular mechanical devices for thrombectomy or thrombus disruption, thromboaspiration, or thrombus entrapment in the vessel wall. The ideal of comprehensive treatment of acute stroke would provide specificity to treat an individual patient: with specific arterial occlusion and collaterals and a determined physiology of acute cerebral ischemia. With all this information, we would decide the best therapeutic strategy for the patient, and move from just a time-based approach to include a pathophysiology approach as well, and thus different patients could have different therapeutic windows. The endovascular treatment situation in Spain is heterogeneous and requires human and material resources to enable it to be implemented throughout the country. CONCLUSIONS: Endovascular treatment of stroke is a new therapeutic tool for achieving reperfusion safely in patients ineligible for Alteplase or who have failed reperfusion with an iv fibrinolytic.

Tratamiento endovascular del ictus isquémico agudo: en busca de la evidencia / Endovascular treatment for acute ischemic stroke: In search of evidence

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Radiological anatomy of the vascularization of cranial dural arteriovenous malformations.

Knowledge of the radiological anatomy of the cranial dural vascularization allows a flexible and appropriate approach to the pretherapeutic investigation of cranial dural arteriovenous malformations. The variability of the origin of these arteries requires that several possible sources of vascular supply be investigated - internal carotid, internal maxillary, ascending pharyngeal, occipital and vertebral - and that each of their meningeal branches be known in detail. Finally, familiarity with the radiological anatomy of these vessels allows one to identify on routine angiography those vessels that may be a source of risk when performing techniques of endovascular therapy (pedicles supplying the cranial nerves, internal carotid and vertebral anastomoses). Each foramen at the base and vault of the cranium contains an artery to the dura mater. Accordingly, very precise topographical study, in particular of the cavernous region, can be made.

The accessory middle cerebral artery (AMCA). Diagnostic and therapeutic consequences.

The existence of the accessory middle cerebral artery (AMCA) is a rare anatomical variation with an estimated incidence of 0.31%. The embryological development of this artery is unknown. Three anatomical subtypes are described: in the type 1 variety the AMCA arises from the internal carotid artery; in the type 2, the AMCA originates from the proximal part of the anterior cerebral artery; in type 3, the AMCA arises from the distal part of the anterior cerebral artery. The use of endovascular techniques to treat cerebral vascular malformations requires knowledge of the anatomical subtype of AMCA and the brain regions it supplies (cortex, basal ganglia).