Intracranial dural arteriovenous fistulas: association with cerebral venous thrombosis, baseline aggressiveness, and clinical outcomes. A retrospective multicenter study on 263 consecutive patients and literature review.

OBJECTIVE: The pathogenesis of intracranial dural arteriovenous fistulas (icDAVFs) is controversial. Cerebral vein thrombosis (CVT) and venous hypertension are recognized predisposing factors. This study aimed to evaluate the incidence of association between icDAVF and CVT and describe baseline aggressiveness and clinical outcomes for icDAVFs associated with CVT. The authors also performed a literature review of studies reporting icDAVF associated with CVT. METHODS: Two hundred sixty-three consecutive patients in two university hospitals with confirmed icDAVFs were included. A double-blind imaging review was performed to determine the presence or absence of CVT close or distant to the icDAVF. Location, type (using the Cognard classification), aggressiveness of the icDAVF, clinical presentation, treatment modality, and clinical and/or angiographic outcomes at 6 months were also collected. All prior brain imaging was analyzed to determine the natural history of onset of the icDAVF. RESULTS: Among the 263 included patients, 75 (28.5%) presented with a CVT concomitant to their icDAVF. For 18 (78.3%) of 23 patients with previous brain imaging available, CVT preceding the icDAVF was proven (6.8% of the overall population). Former/active smoking (OR 2.0, 95% CI 1.079-3.682, p = 0.022) and prothrombogenic status (active inflammation or cancer/coagulation trouble) were risk factors for CVT associated with icDAVF (OR 3.135, 95% CI 1.391-7.108, p = 0.003). One hundred eighty-seven patients (71.1%) had a baseline aggressive icDAVF, not linked to the presence of a CVT (p = 0.546). Of the overall population, 11 patients (4.2%) presented with spontaneous occlusion of their icDAVF at follow-up. Seven patients (2.7%) died during the follow-up period. Intracranial DAVF + CVT was not associated with a worse prognosis (modified Rankin Scale score at 3-6 months: 0 [interquartile range {IQR} 0-1] for icDAVF + CVT vs 0 [IQR 0-0] for icDAVF alone; p = 0.055). CONCLUSIONS: This was one of the largest studies focused on the incidence of CVT associated with icDAVF. For 6.8% of the patients, a natural history of CVT leading to icDAVF was proven, corresponding to 78.3% of patients with previous imaging available. This work offers further insights into icDAVF pathophysiology, aiding in identifying high-risk CVT patients for long-term follow-up imaging. Annual imaging follow-up using noninvasive vascular imaging (CT or MR angiography) for a minimum of 3 years after the diagnosis of CVT should be considered in high-risk patients, i.e., smokers and those with prothrombogenic status.

Superselective 3D digital subtraction angiography and magnetic resonance fusion imaging for the management of micro-arteriovenous malformations.

Cerebral micro-arteriovenous malformations (AVM) are defined by an infracentimetric nidus or a nidus solely visible on superselective digital subtraction angiography (DSA).12 While representing a minority of brain AVMs, intracerebral hemorrhage is a frequent manifestation in this subset of AMVs.2 Micro-AVMs are often occult lesions, with superselective DSA being instrumental for increasing diagnostic yield.13 While superselective three-dimensional DSA (3D-DSA)/MR fusion imaging has been employed to better delineate anatomical proximity in cerebral AVMs with a visible nidus on MRI,4 this fusion algorithm has not yet been used for describing the relationship of micro-AVMs nidus and afferent arteries with neighboring structures, in order to guide endovascular and microsurgical procedures. In this technical video (Video 1), we present 3 cases regarding micro-AVM embolization, in which superselective 3D-DSA/MR fusion imaging aided therapeutic decision, by defining the local anatomy and allowing a safer procedure.

Radial artery occlusion after aneurysm treatment using the rist guide catheter: Single center cohort study.

BACKGROUND AND PURPOSE: Delayed radial artery occlusion (dRAO) is a frequent complication after transradial access (TRA) for neurointervention when using standard large guide catheters. The RIST 079 guide catheter (RIST GC) is the first catheter designed for TRA in neurointervention. We aimed to assess the rate of dRAO after intracranial aneurysm (IA) treatment using the RIST GC. METHODS: Patients treated for an IA using TRA and the RIST GC between June 2021 and November 2022 were referred to a systematic US-doppler assessment of the radial artery patency at 3-month follow-up. Patients with and without dRAO were compared to identify risk factors. RESULTS: Twenty-two patients were included in the analysis. At 3-months follow up, 6 patients (27.3 %) presented with dRAO. Four patients were asymptomatic and 2 experienced post-operative radial hematoma and wrist pain. There was a tendency towards younger age, longer procedure duration and higher rate of forearm hematoma in patients with dRAO. Navigation using the RIST GC was successful in 90.9 % of cases. Intracranial access failures and navigation complications were all related to left internal carotid artery navigation. CONCLUSIONS: At 3-month follow up, 27.3 % of patients treated for IA using TRA with the RIST GC presented dRAO.

Exclusion treatment of ruptured and unruptured low-grade brain arteriovenous malformations: a systematic review.

PURPOSE: To assess the obliteration rate, functional outcome, hemorrhagic complication, and mortality rates of exclusion treatment of low-grade brain arteriovenous malformations (BAVMs) (Spetzler and Martin grades (SMGs) 1 and 2), either ruptured or unruptured. METHODS: Electronic databases-Ovid MEDLINE and PubMed-were searched for studies in which there was evidence of exclusion treatment of low-grade BAVMs treated either by endovascular, surgical, radiosurgical, or multimodality treatment. The primary outcome of interest was angiographic obliteration post-treatment and at follow-up. The secondary outcomes of interest were functional outcome (mRS), mortality rate, and hemorrhagic complication. Descriptive statistics were used to calculate rates and means. RESULTS: Eleven studies involving 1809 patients with low-grade BAVMs were included. Among these, 1790 patients treated by either endovascular, surgical, radiosurgical, or multimodality treatment were included in this analysis. Seventy-two percent of BAVMs were Spetzler-Martin grade II. The overall (i.e., including all exclusion treatment modalities) complete obliteration rate ranged from 36.5 to 100%. The overall symptomatic hemorrhagic complication rate ranged from 0 to 7.3%; procedure-related mortality ranged from 0 to 4.7%. CONCLUSION: Our systematic review of the literature reveals a high overall obliteration rate for low-grade BAVMs, either ruptured or unruptured, with low mortality rate and an acceptable post-treatment hemorrhagic complication rate. These results suggest that exclusion treatment of low-grade BAVMs may be safe and effective, regardless of the treatment modality chosen.

Anterior interhemispheric approach for anterior fossa dural arteriovenous fistulas.

Anterior fossa dural arteriovenous fistulas (AF-DAVF) usually display a cortical venous drainage and are therefore at risk for rupture. Microsurgery is traditionally considered in many centers as the first-line treatment since endovascular treatment (EVT) entails a lower cure rate and significant ophthalmic risks. The anterior interhemispheric approach (AIA), originally described by Mayfrank in 1996, seems to offer the effectiveness of microsurgery while limiting the risks related to subfrontal craniotomy. The objective of this study was to analyze the surgical outcomes of patients who underwent this surgical approach for the treatment of AF-DAVF. We hereby describe our 10 years' experience of patients treated for an AF-DAVF with this technique in our institution and retrospectively analyzed our results. In addition, we describe our operative technique and its specificities. Eleven patients with AF-DAVF were included in our study. The definitive cure of the fistula was confirmed in all cases with postoperative cerebral angiography. All patients had a good neurological outcome and no major complication occurred. Brain retractors were never used during surgery, the frontal sinus was never opened neither, and anosmia was never observed after surgery. Anterior interhemispheric approach seems to be safe and effective to treat AF-DAVF with lower risks than other surgical approaches. This technique could be more widely considered when facing such midline vascular lesion.

Safety and effectiveness of mechanical thrombectomy for primary isolated distal vessel occlusions: A monocentric retrospective comparative study.

BACKGROUND: Distal vessel occlusions represent about 25-40% of acute ischemic stroke (AIS), either as primary occlusion or secondary occlusion complicating mechanical thrombectomy (MT) for large vessel occlusion. OBJECTIVE: Our aim was to evaluate safety and effectiveness of MT associated with the best medical treatment (BMT) in the management of AIS patients with distal vessel occlusion in comparison with the BMT alone. METHODS: Retrospective analysis was conducted on AIS patients treated by MT+BMT for primary distal vessel occlusion between 2015 and 2020, and were compared with a historic cohort managed by BMT alone between 2006 and 2015 selected based on the same inclusion criteria. A secondary analysis was conducted using propensity score matching (PSM) including the following: NIHSS, age and treatment with intravenous thrombolysis (IVT) as covariates. RESULTS: Of 650 patients screened, 44 patients with distal vessel occlusions treated by MT+BMT were selected and compared with 36 patients who received BMT alone. After PSM, 28 patients in each group were matched without significant difference. Good clinical outcome defined as mRS≤2 was achieved by 53.6% of the MT+BMT group and 57% of the BMT group (OR, 0.87; 95%CI, 0.3-2.4; p = 1.00). The mortality rate was comparable in both groups (7% vs. 10.7% in MT+BMT and BMT patients, respectively; OR=0.64; 95%CI, 0.1-4; p = 1.00). Symptomatic intracranial hemorrhage (ICH) was seen in only one patient treated by MT+BMT (3.6%). CONCLUSION: Mechanical thrombectomy seems to be comparable with the best medical treatment regarding the effectiveness and safety in the management of patients with distal vessel occlusions.

Benefit of mechanical thrombectomy in acute ischemic stroke related to calcified cerebral embolus.

PURPOSE: Mechanical thrombectomies (MT) in patients with large vessel occlusion (LVO) related to calcified cerebral embolus (CCE) have been reported, through small case series, being associated with low reperfusion rate and worse outcome, compared to regular MT. The purpose of the MASC (Mechanical Thrombectomy in Acute Ischemic Stroke Related to Calcified Cerebral Embolus) study was to evaluate the incidence of CCEs treated by MT and the effectiveness of MT in this indication. METHODS: The MASC study is a retrospective multicentric (n = 37) national study gathering the cases of adult patients who underwent MT for acute ischemic stroke with LVO related to a CCE in France from January 2015 to November 2019. Reperfusion rate (mTICI ≥ 2B), complication rate and 90-day mRS were systematically collected. We then conducted a systematic review by searching for articles in PubMed, Cochrane Library, Embase and Google Scholar from January 2015 to March 2020. A meta-analysis was performed to estimate clinical outcome at 90 days, reperfusion rate and complications. RESULTS: We gathered data from 35 patients. Reperfusion was obtained in 57% of the cases. Good clinical outcome was observed in 28% of the patients. The meta-analysis retrieved 136 patients. Reperfusion and good clinical outcome were obtained in 50% and 29% of the cases, respectively. CONCLUSION: The MASC study found worse angiographic and clinical outcomes compared to regular thrombectomies. Individual patient-based meta-analysis including the MASC findings shows a 50% reperfusion rate and a 29% of good clinical outcome.

State of the Art: Venous Causes of Pulsatile Tinnitus and Diagnostic Considerations Guiding Endovascular Therapy.

Venous variants and pathologic abnormalities are the most common causes of pulsatile tinnitus. These conditions include causes of turbulence within normally located veins and sinuses, and abnormally enlarged or abnormally located veins in close transmissive proximity to the conductive auditory pathway. Such disorders include pathologic abnormalities of the lateral sinus (transverse sinus stenosis and sigmoid sinus wall anomalies), abnormalities and variants of the emissary veins, and anomalies of the jugular bulb and jugular vein. Despite being the most common causes for pulsatile tinnitus, venous variants and pathologic abnormalities are often overlooked in the workup of pulsatile tinnitus. Such oversights can result in delayed patient care and prolonged patient discomfort. Advances in both cerebrovascular imaging and endovascular techniques allow for improved diagnostic accuracy and an increasing range of endovascular therapeutic options to address pulsatile tinnitus. This review illustrates the venous causes of pulsatile tinnitus and demonstrates the associated endovascular treatment. © RSNA, 2021.

Reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography in hypervascular spinal metastases prior embolization.

OBJECTIVES: Preoperative embolization of hypervascular spinal metastases (HSM) is efficient to reduce perioperative bleeding. However, intra-arterial digital subtraction angiography (IA-DSA) must confirm the hypervascular nature and rule out spinal cord arterial feeders. This study aimed to evaluate the reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography (TR-CE-MRA) in assessing HSM prior to embolization. METHODS: All consecutive patients referred for preoperative embolization of an HSM were prospectively included. TR-CE-MRA sequences and selective IA-DSA were performed prior to embolization. Two readers independently reviewed imaging data to grade tumor vascularity (using a 3-grade and a dichotomized "yes vs no" scale) and identify the arterial supply of the spinal cord. Interobserver and intermodality agreements were estimated using kappa statistics. RESULTS: Thirty patients included between 2016 and 2019 were assessed for 55 levels. Interobserver agreement was moderate (κ = 0.52; 95% CI [0.09-0.81]) for TR-CE-MRA. Intermodality agreement between TR-CE-MRA and IA-DSA was good (κ = 0.74; 95% CI [0.37-1.00]). TR-CE-MRA had a sensitivity of 97.9%, a specificity of 71.4%, a positive predictive value of 95.9%, a negative predictive value of 83.3%, and an overall accuracy of 94.6%, for differentiating hypervascular from non-hypervascular SM. The arterial supply of the spine was assessable in 2/30 (6.7%) cases with no interobserver agreement (κ < 0). CONCLUSIONS: TR-CE-MRA can reliably differentiate hypervascular from non-hypervascular SM and thereby avoid futile IA-DSAs. However, TR-CE-MRA was not able to evaluate the vascular supply of the spinal cord at the target levels, thus limiting its scope as a pretherapeutic assessment tool. KEY POINTS: • TR-CE-MRA aids in distinguishing hypervascular from non-hypervascular spinal metastases. • TR-CE-MRA could avoid one-quarter of patients referred for HSM embolization to undergo futile conventional angiography. • TR-CE-MRA's spatial resolution is insufficient to replace IA-DSA in the pretherapeutic assessment of the spinal cord vascular anatomy.

Idiopathic Intracranial Hypertension: Glymphedema of the Brain.

BACKGROUND: During the last decade, our understanding of cerebrospinal fluid (CSF) physiology has dramatically improved, thanks to the discoveries of both the glymphatic system and lymphatic vessels lining the dura mater in human brains. EVIDENCE ACQUISITION: We detail the recent basic science findings in the field of CSF physiology and connect them with our current understanding of the pathophysiology of idiopathic intracranial hypertension (IIH). RESULTS: Transverse sinus (TS) stenoses seem to play a major causative role in the symptoms of IIH, as a result of a decrease in the pressure gradient between the venous system and the subarachnoid space. However, the intracranial pressure can be highly variable among different patients, depending on the efficiency of the lymphatic system to resorb the CSF and on the severity of TS stenoses. It is likely that there is a subclinical form of IIH and that IIH without papilledema is probably under-diagnosed among patients with chronic migraines or isolated tinnitus. CONCLUSIONS: IIH can be summarized in the following pathological triad: restriction of the venous CSF outflow pathway-overflow of the lymphatic CSF outflow pathway-congestion of the glymphatic system. To better encompass all the stages of IIH, it is likely that the Dandy criteria need to be updated and that perhaps renaming IIH should be considered.

Dural arteriovenous fistula formation following bilateral middle meningeal artery embolization for the treatment of a chronic subdural hematoma: a case report.

Here is reported a case of dural arteriovenous fistula (DAVF) formation following middle meningeal artery (MMA) embolization. A 64-year-old male patient was operated for a bilateral CSDH by burr-hole craniostomy. Prophylactic post-operative MMA embolization was performed with 300-500-µm calibrated microparticles. The patient was admitted 3 months later for a left CSDH recurrence. Digital subtraction angiography demonstrated formation of a superior sagittal sinus DAVF fed by both superficial temporal arteries. This case highlights the possible role of local tissue hypoxia as a significant component of DAVF pathogenesis. Moreover, it has potential implications for MMA embolization as a management strategy for CSDH.

Is Anatomical Variations a Risk Factor for Cerebral Vasospasm in Anterior Communicating Complex Aneurysms Rupture?

Background and Purpose- One-third of ruptured aneurysms are located on the anterior communicating complex with high prevalence of anatomic variations of this arterial segment. In this study, we hypothesized that anatomic variations of the anterior communicating complex increase the risk of angiographic vasospasm. Methods- Retrospective study of prospectively collected data from a monocentric subarachnoid hemorrhage cohort of patients admitted to neurointensive care between 2002 and 2018. Univariate followed by multivariate logistic regression analysis was used to identify factors associated with angiographic vasospasm. Results- One thousand three hundred seventy-four patients with aneurismal subarachnoid hemorrhage were admitted to our institution; 29.8% (n=410) were related to an anterior communicating complex aneurysm rupture; 9.2% (n=38) of them showed an anterior communicating artery variation. Angiographic vasospasm was diagnosed in 55.6% of this subgroup (vs 28.1%, P=0.003). In the multivariate analysis, external ventricular drain (2.2 [1.32-3.65], P=0.003) and anterior communicating artery variation (2.40 [1.2-4.9], P=0.04) were independently and significantly associated with angiographic vasospasm, while age above 60 years (0.3 [0.2-0.7]; P=0.002) was a protective factor. However, anterior communicating artery variation was not statistically associated with ischemic vasospasm or poor neurological outcome after anterior communicating artery aneurysm rupture. Conclusions- Anatomic variation of anterior communicating artery could be a new biomarker to identify patients at risk to develop angiographic vasospasm post-subarachnoid hemorrhage. External validation cohorts are necessary to confirm these results.

Rescue stenting versus medical care alone in refractory large vessel occlusions: a systematic review and meta-analysis.

PURPOSE: Mechanical thrombectomy (MT) failure is associated with very poor prognosis. Permanent intracranial stenting (PIS) may be useful in such refractory occlusions. However, this strategy requires an aggressive antithrombotic regimen that may be harmful in extended strokes. The aim of this study was to compare clinical outcomes between patients with refractory acute large vessel occlusions (LVOs) treated by PIS versus patients for whom the procedure was stopped without recanalization. METHODS: We conducted a systematic review by searching for articles in PubMed, the Cochrane Library, and ClinicalTrials.gov from January 2015 to September 2019. Two reviewers independently selected studies comparing PIS after failed MT in addition to usual care versus usual care only. A comparative meta-analysis was performed using random-effects models to estimate odds ratios of favorable clinical outcome at 90 days, defined as a modified Rankin scale 0-2, mortality and symptomatic intracranial hemorrhage (SICH). RESULTS: Four comparative studies were included for a total of 352 patients: 149 in the PIS group versus 203 in the control group. PIS was associated with significantly higher rates of 90-day favorable clinical outcome (odds ratio [OR], 2.87 [95% confidence interval (95% CI), 1.77-4.66]; p < 0.001; I2, 0%) and lower mortality (OR, 0.39 [0.16-0.93]; p = 0.03; I2, 43%), whereas SICH rates did not significantly differ (OR, 0.68 [0.37-1.27]; p = 0.23; I2, 0%). CONCLUSION: From observational study results, attempting PIS after failed MT seems to improve clinical outcomes without increasing the risk of intracranial bleeding. Randomized trials are needed to confirm these results.

Wall Shear Stress in the Feeding Native Conduit Arteries of Superficial Arteriovenous Malformations of the Lower Face is a Reliable Marker of Disease Progression.

PURPOSE: To assess the prognostic value of the wall shear stress (WSS) measured in the feeding native arteries upstream from facial superficial arteriovenous malformations (sAVMs). Reliable prognostic criteria are needed to distinguish progressive from stable sAVMs and thus support the indication for an aggressive or a conservative management to avoid severe facial disfigurement. MATERIALS AND METHODS: We prospectively included 25 patients with untreated facial sAVMs, 15 patients with surgically resected sAVMs and 15 controls. All had undergone Doppler ultrasound examination (DUS) with measurements of inner diameters, blood flow velocities, computation of blood flow and WSS of the feeding arteries. Based on the absence or presence of progression in clinical and imaging examinations 6 months after, we discriminated untreated patients as stable or progressive. RESULTS: WSS in the ipsilateral external carotid artery was higher in progressive compared to stable sAVMs (15.8 ±â€Š3.3dynes/cm² vs. 9.6 ±â€Š2.0dynes/cm², mean±SD, p < 0.0001) with a cut-off of 11.5dynes/cm² (sensitivity: 92 %, specificity: 92 %, AUC: 0.955, [95 %CI: 0.789-0.998], p = 0.0001). WSS in the ipsilateral facial artery was also higher in progressive compared to stable sAVMs (50.7 ±â€Š14.5dynes/cm² vs. 25.2 ±â€Š7.1dynes/cm², p < 0.0001) with a cut-off of 34.0dynes/cm² (sensitivity: 100 %, specificity: 92 %, AUC: 0.974, [95 %CI: 0.819-1.000], p = 0.0001). The hemodynamic data of operated patients were not different from those of the control group. CONCLUSION: WSS measured in the feeding arteries of an sAVM may be a simple reliable criterion to distinguish stable from progressive sAVMs. This value should be considered to guide the therapeutic strategy as well as the long-term follow-up of patients with facial sAVMs.

Secondary S100B Protein Increase Following Brain Arteriovenous Malformation Rupture is Associated with Cerebral Infarction.

Early S100B protein serum elevation is associated with poor prognosis in patients with ruptured brain arteriovenous malformations (BAVM). The purpose of this study is to determine whether a secondary elevation of S100B is associated with early complications or poor outcome in this population. This is a retrospective study of patients admitted for BAVM rupture. A secondary increase of S100B was defined as an absolute increase by 0.1 µg/L within 30 days of admission. Fisher's and unpaired t tests followed by multivariate analysis were performed to identify markers associated with this increase. Two hundred and twenty-one ruptures met inclusion criteria. Secondary S100B protein serum elevation was found in 17.1% of ruptures and was associated with secondary infarction (p < 0.001), vasospasm-related infarction (p < 0.001), intensive care (p = 0.009), and hospital length of stay (p = 0.005), but not with early rebleeding (p = 0.07) or in-hospital mortality (p = 0.99). Secondary infarction was the only independent predictor of secondary increase of S100B (OR 9.9; 95% CI (3-35); p < 0.001). Secondary elevation of S100B protein serum levels is associated with secondary infarction in ruptured brain arteriovenous malformations.

Outcome and recanalization rate of tandem basilar artery occlusion treated by mechanical thrombectomy.

BACKGROUND: Tandem basilar artery occlusions (tBAO) are defined as concomitant basilar artery and extracranial dominant vertebral artery occlusions. The prognosis of such tBAO treated by mechanical thrombectomy (MT) has been scantly reported. The purpose of our study was to compare the safety and effectiveness of MT for patients with tBAO compared to those with non-tandem basilar artery occlusions (ntBAO). PATIENTS AND METHODS: Retrospective analysis of a database of patients who underwent MT at two academic centres. All patients treated for BAO were retrieved. Patients with tBAO, defined as a concomitant BAO and extracranial vertebral artery (VA) occlusion or severe stenosis ≥70% (V1 or proximal V2 segment) were compared with patients with ntBAO. RESULTS: A total of 15 patients with tBAO and 74 patients with ntBAO were enrolled. Successful reperfusion (modified thrombolysis in cerebral infarction score ≥2b) was obtained in 73.3% versus 90.5% (OR = 0.29, 95%CI: 0.07-1.15), good clinical outcome (3-months modified Rankin scale ≤2) was reached by 26.7% versus 32.4% (OR = 0.76; 95% CI: 0.24-2.63) and mortality at 3-months was 46.7% versus 31% (OR = 1.94; 95%CI: 0.63-6) of patients with tBAO versus ntBAO, respectively. Two patients (13.3%) with tBAO and three (4%) with ntBAO had symptomatic intracranial haemorrhage (OR = 3.64; 95% CI: 0.55-24). CONCLUSION: Mechanical thrombectomy for patients with tandem basilar artery occlusion tends to be associated with lower rates of successful reperfusion and good clinical outcome, and higher rate of mortality. Larger multicentre studies are warranted to better precise the proper selection and management of such patients.

S100B Serum Elevation Predicts In-Hospital Mortality After Brain Arteriovenous Malformation Rupture.

Background and Purpose- S100B protein serum elevation has been associated with poor prognosis in neurologically ill patients. The purpose of this study is to determine whether elevation of S100B is associated with increased in-hospital mortality after brain arteriovenous malformation rupture. Methods- This is a retrospective study of patients admitted for brain arteriovenous malformation rupture. The study population was divided into derivation and validation cohorts. Univariate followed by multivariate logistic regression was used to determine whether elevation of S100B serum levels above 0.5 µg/L during the first 48 hours after admission (S100Bmax48) was associated with in-hospital mortality. Results- Two hundred and three ruptures met inclusion criteria. Twenty-three led to in-hospital mortality (11%). Mean S100Bmax48 was 0.49±0.62 µg/L. In the derivation cohort (n=101 ruptures), multivariate analysis found Glasgow coma scale score ≤8 (odds ratio, 21; 95% CI, 2-216; 0.001) and an S100Bmax48>0.5 µg/L (odds ratio, 19; 95% CI, 2-188; P=0.001) to be associated with in-hospital mortality. When applied to the validation cohort (n=102 ruptures), the same model found only S100Bmax48>0.5 µg/L (odds ratio, 8; 95% CI, 1.5-44; P=0.01) to be associated with in-hospital mortality. Conclusions- Elevated S100B protein serum level is strongly associated with in-hospital mortality after brain arteriovenous malformation rupture.

Platelet activation and aggregation after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Endovascular techniques have proven beneficial in the treatment of aneurysmal subarachnoid hemorrhage (aSAH), but with high risk of arterial clotting, emboli and dissection. Platelet activation and alterations in hemostasis may contribute to these complications. We investigated platelet activation and aggregation pathways in aSAH patients who underwent endovascular treatment. METHODS: Two blood samples were taken, in the early days after bleeding and during the period at risk of vasospasm. We studied platelet activation through the expression of GpIIbIIIa and P-selectin as well as aggregation rate in the presence of agonists. Platelets from aSAH patients were compared with those from orthopedic postoperative patients (POSTOP). RESULTS: Platelets in aSAH were initially spontaneously activated and remained so over time. aSAH platelets were further activated with rapid aggregation in the presence of agonists, particularly ADP, with behavior comparable to POSTOP platelets. CONCLUSIONS: aSAH platelets showed prolonged increases in activation and aggregation. Therapies targeting the ADP pathway might reduce the risk of clotting and ischemic events in this context among patients requiring multiple endovascular procedures. TRIAL REGISTRATION: Not applicable.

Surgical Treatment of Venous Malformations of the Knee: Treatment Outcomes for 35 Patients.

BACKGROUND: The place of open surgery in venous malformations (VMs) of knee joint is still discussed. The aim of this study was to evaluate the benefits of surgery in terms of pain, function, and quality of life. DESIGN: This was a retrospective observational study. METHODS: Thirty-five consecutive young patients undergoing surgery for VMs of the knee between 2011 and 2014 were included. Data collection was performed using a prospective database by reviewing patient records. Pain, mobility of the joint, residual VMs as seen by magnetic resonance imaging, and quality of life were the main outcome endpoints for this study. RESULTS: Thirty-five patients (22 females and 13 males, with a median age of 15 y, range of 5 to 20 y) were included. Twenty-seven VMs were localized in and around the knee joint, of which 8 were extensive. Indication for surgery was intermittent or permanent pain.Details of the surgical excisions of the VM are as follows: suprapatellar area in 57%, suprapatellar and infrapatellar area in 29%, infrapatellar area in 2%, limited in the femoropatellar area in 12%. Partial resection of a vastus muscle or patellar retinaculum was necessary for 19 patients.The median duration of the surgery was 4 hours (range: 2 to 7 h). The median hospital stay was 5 days; full-time physiotherapy was systematic for 2 to 3 weeks.After 6 months, 74% had no longer pain, the mobility of the joint was normal for 60%. Of the 33 patients who had a magnetic resonance imaging at 6 months, 86% (28 patients) had no residual intra-articular VMs, and 14% had focal residual VMs.At the last follow-up, 77% (27 patients) had no longer pain, 23% experienced intermittent pain with unusual activities, and 91% (32 patients) had normal mobility of the joint. Quality of life was increased significantly due to the pronounced impact on pain. CONCLUSION: Extensive surgical excision of knee VMs is a safe procedure with good outcomes in terms of pain, function, and quality of life. LEVEL OF EVIDENCE: Level II-retrospective observational monocentric study.

Velocity-pressure loops for continuous assessment of ventricular afterload: influence of pressure measurement site.

VPloop, the graphical representation of pressure versus velocity, and its characteristic angles, GALA and ß, can be used to monitor cardiac afterload during anesthesia. Ideally VPloop should be measured from pressure and velocity obtained at the same arterial location but standard of care usually provide either radial or femoral pressure waveforms. The purpose of this study was to look at the influence of arterial sites and the use of a transfer function (TF) on VPloop and its related angles. Invasive pressure signals were recorded in 25 patients undergoing neuroradiology intervention under general anesthesia with transesophageal flow velocity monitoring. Pressures were recorded in the descending thoracic aorta, abdominal aorta, femoral and radial arteries. We compared GALA and ß from VPloops generated from each location and in high and low risk patients. GALA was similar in the central locations (55°[49-63], 52°[47-61] and 54°[45-62] from descending thoracic to femoral artery, median[interquartile], p = 0.10), while there was a difference in ß angle (16°[4-27] to 8°[3-15], p < 0.0001). GALA and ß obtained from radial waveforms were different (39°[31-47] compared to 46°[36-54] and 6°[2-14] compared to 16°[4-27] for GALA and ß angles respectively, p < 0.001) which was corrected by the use of a TF (45°[32-55] and 17°[5-28], p = ns). GALA and ß are underestimated when measured with a radial catheter. Using pressure waveforms from femoral locations alters VPloops, GALA and ß in a smaller extend. The use of a TF on radial pressure allows to correctly plot VPloops and their characteristic angles for routine clinical use.