Rare clinical presentation of a ruptured spinal bulbomedullary arteriovenous malformation: a case report.

Introduction and importance: Spinal arteriovenous malformations (AVMs) are a rare condition that has a high risk of bleeding and complications. The authors present the case of a spinal arteriovenous malformation in an unusual location and presentation. Case presentation: A 67-year-old man with subarachnoid hemorrhage due to a ruptured spinal arteriovenous malformation type IVa, with associated bulbomedullary aneurysm, which was managed conservatively due to the high risk of complications and mortality. Clinical discussion: Spinal AVMs have had different management and treatments over the years, so conservative management remains an option when arterial cannulation is complex and surgery carries a high risk of complications. Conclusion: Due to the high risk of complications of surgery in this location, conservative treatment is an option for the management of such cases with good outcomes.

Extended time window mechanical thrombectomy for pediatric acute ischemic stroke.

Endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) remains an off-label procedure seldom utilized in the pediatric population; this holds especially true for patients presenting outside the standard 6-hour time window. In this review we describe the published literature regarding usage of the extended time window EVT in pediatric stroke. We searched PubMed for all pediatric AIS cases and case series that included patients treated with extended time window EVT. We found data from 38 cases found in 27 publications (15 case reports and 12 case series). The median age was 10 years; 60.5% males. The median NIHSS before EVT was 13 with a median time-to-treatment of 11 hours. The posterior circulation was involved in 50.0%. Stent retrievers were used in 68.5%, and aspiration in 13.2%. Angiographic outcome TICI ≥2B was achieved in 84.2%, whereas TICI˂2B was reported in 10.6%. A favorable clinical outcome (NIHSS score ≤4, modified Rankin score ≤1, or Pediatric Stroke Outcome measure score ≤1) occurred in 84.2%. Eight cases that did not report the clinical outcome employing a standardized scale described mild to absent neurological residual deficits. This study found data that supports that extended window EVT produces high recanalization rates and good clinical outcomes in pediatric patients with AIS. Nevertheless, the source materials are indirect and contain substantial inconsistencies with an increased risk of bias that amount to low evidence strength.

Endovascular Treatment of Ischemic Stroke in a Developing Country.

BACKGROUND: There is inequality in access to recent advancements in endovascular treatment of acute ischemic stroke (AIS), and Mexico is unusually sensitive to such inequality. AIMS: To report the initial experience of the Mexican Endovascular Reperfusion Registry (MERR). METHODS: The MERR is an academic, independent, prospective, multicenter, observational registry of patients treated with endovascular reperfusion techniques in Mexican hospitals. The registry includes information on demographic and clinical characteristics, diagnostic procedures, treatments, selected time metrics, and outcomes. RESULTS: In all, 49 (57.1% female) patients from 8 centers were included and had the following characteristics: median National Institute of Health Stroke Scale score, 16; median Alberta Stroke Program Early CT Score score, 9; received intravenous tissue-type plasminogen activator, 49%; and treated with mechanical devices, 39 (79.6%), including 20 treated with stent retriever alone, 2 with retriever and intra-arterial thrombolysis (IAt), 10 with catheter aspiration (4 in combination with IAt), 6 with a combination of catheter aspiration and stent retriever, and 1 with IAt followed by balloon angioplasty. Recanalization (TICI 2b or better) was achieved in 69.4% of the patients. The median clot to recanalization time was 30 minutes. A modified Rankin scale ≤2 was achieved in 44.9% of the patients, and 68.2% of these were treated with stent retriever (P = .011). Procedure-related morbidity was 12.2%, 7 patients presented intracerebral hemorrhage (71.4% asymptomatic), and all-cause mortality was 6.1%. CONCLUSIONS: Endovascular treatment of AIS in Mexico is feasible and has an efficacy comparable to that of other countries. Still, many challenges remain, especially pertaining to high costs and difficulties in equality in access to treatment.

Use of the sole stenting technique for the management of aneurysms in the posterior circulation in a prospective series of 20 patients.

OBJECT: The use of intracranial stents in stent-assisted coil embolization is now a current neurosurgical practice worldwide. The clinical utility of these stents in the sole stenting (SS) technique, however, has not been thoroughly described, and the published reports of this experience are scarce. This study was designed to evaluate SS treatment of dissecting and nondissecting aneurysms of the posterior circulation. METHODS: This prospective and descriptive study was conducted in 20 consecutive patients who harbored single aneurysms of the posterior circulation and who were treated using the SS approach in the last 3 years. The clinical and radiological assessment and follow-up of the patients were evaluated using the modified Rankin scale as well as with computed tomography angiography and digital subtraction angiography at discharge and at 1, 3, 6, and 12 months. RESULTS: Eleven of the 20 patients had subarachnoid hemorrhages, 3 presented with ischemia, 1 presented with brainstem compression, and the remaining 5 patients had incidentally discovered, asymptomatic lesions. Only 1 patient had a complication (occipital infarction) attributable to the SS procedure. One patient died of rebleeding 2 weeks after the procedure. At 1 month, 40% of the patients had a subtotal or total occlusion, which increased to 55% at 3 months and 85% at 6 months, with a final subtotal or total occlusion rate of 80% at 1 year. The SS procedure in 1 case was considered a failure at 6 months because no change had been noted since the 1-month follow-up. One case showed partial occlusion and 1 case showed recanalization. CONCLUSIONS: Use of SS for aneurysms in the posterior circulation complex is a safe and effective technique, demonstrating an occlusion rate of 80% at the 1-year follow up.

Superior cerebellar artery aneurysms treated using the sole stenting approach. Technical note.

Endovascular treatment of intracranial aneurysms has evolved since the introduction of detachable coils. Sole stenting is a brand-new technique that has recently emerged as a definitive treatment for saccular or fusiform aneurysms at particular locations. Superior cerebellar artery aneurysms are rare, and few treated cases have been reported. Most of them have been treated surgically, and endovascular cases usually have been managed with occlusion of the parent vessel. The authors report on the first two endovascularly treated cases with complete cure of the aneurysm as well as preservation of the parent vessel and distal circulation via the sole stenting technique. The results together with several aspects of the technique, such as the correction of the angle of the vessel and modification of the shear stress, are discussed.

Intracranial arterial stenting for symptomatic stenoses: a Latin American experience.

BACKGROUND: The proportionally higher incidence of intracranial atherosclerosis among Asian and black patients and a greater proclivity for intracranial artery stenosis in the Hispanic population merit drawing attention to a Latin American experience with intracranial arterial stenting. METHODS: This is a retrospective analysis of an observational study of 33 intracranial lesions (each >50% stenosis) in 32 patients treated by intracranial angioplasty in 6 Latin American centers over a 3-year period. The investigation used a unique device, a balloon-expandable stent (Lekton Motion stent system, now Pharos, Biotronik, AG, Bülach, Switzerland). RESULTS: The treated patients ranged in age from 30 to 81 years (mean, 59.3 years; SD, 12 years), including 24 male and 8 female patients (sex ratio, 4:1). Two were Asians, 4 were blacks, and the rest were white Hispanic. Our mean follow-up is of 10.2 months (SD, 7.84 months), with a mortality rate of 9.4% (3/32), a nonfatal complication rate of 6.2%, and a stroke rate (rate of recurrence) of 0%. The mean pretreatment stenosis of 68.75% (SD, 14%) was reduced to a residual of 5.16% (SD, 16%) (P = .000; 95% confidence interval, 56.8%-70.3%). A control angiogram was performed in 82% of patients, and in that case, the restenosis 50% or greater was of 8.7% during the follow-up period. CONCLUSION: The treatment of intracranial stenosis with the Lekton Motion stent (Pharos) is feasible with a high technical success rate. Restenosis as well as the rate of new neurologic events during follow-up suggests some efficacy of stroke prevention by using the latest-generation, highly trackable, balloon-expandable stents.

Balloon-expandable stenting with and without coiling for wide-neck and complex aneurysms.

BACKGROUND: Wide-necked, saccular, dissecting, and fusiform intracranial aneurysms are poor coil retainers. Retention can be improved by parent-artery stenting across the aneurysm. METHODS: We used a balloon-expandable stent and delivery system, intending to treat 38 aneurysms in 36 patients. Stents could not be advanced across the neck of 2 aneurysms near the ophthalmic artery origin. These cases were managed by temporary balloon remodeling and coiling. Stenting alone was done for 15 aneurysms, including 7 in vertebral artery V4 segments. Stenting with immediate or delayed coiling was done in 21 aneurysms. RESULTS: Stenting alone caused immediate and complete obliteration of 1 treated aneurysm (7%), subtotal obliteration in 13 treated (86%) aneurysms, and was associated with 1 failure. Stenting and coiling yielded a significantly better 57% complete obliteration rate, 43% subtotal obliteration, and no failures. There were 5 complications: 1 wire perforation, 2 cavernous-carotid-sinus fistulae, and 2 partial in-stent thromboses. All were controlled or cleared with no long-term sequelae or deaths. Contrast imaging at 1 to 12 months was available for 30 patients (13 stent-only, 17 stent-plus-coiling), demonstrating complete obliteration in 25 (83%) and subtotal obliteration in 5. A total of 7 stent-only aneurysms (4 V4s) were completely obliterated, and 3 (all V4s) were > or = 90% obliterated. CONCLUSION: Stenting and coiling through the wall of the stent resulted in 88% (15/17) complete obliteration when imaged 1 to 12 months after treatment. Stenting alone effectively closed off V4-segment wide-necked aneurysms but was inferior to stenting and coiling in less mobile vessels.

Clinical presentation and magnetic resonance findings in sellar tuberculomas.

Background and Importance. Sellar tuberculomas are extremely rare lesions with nonspecific clinical manifestations. The tuberculous infection of the pituitary gland and sellar region is characterized by the presence of an acute or chronic inflammatory reaction and may occur in the absence of systemic tuberculosis. The diagnosis is difficult prior to the surgery. An adequate diagnostic and antituberculous drugs usually result in a good outcome. Clinical Presentation. We report four cases of sellar tuberculoma, 3/1 female/male, age range: 50-57 years. All patients had visual disturbances and low levels of cortisol. Conclusion. The clinical diagnosis of sellar tuberculoma is a challenge and should be suspected when a sellar lesion shows abnormal enhancement pattern and stalk involvement, and absence of signal suppression in FLAIR.

Endovascular treatment: balloon angioplasty versus nimodipine intra-arterial for medically refractory cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

Cerebral vasospasm (CV) accounts significant morbimortality after aneurysmal subarachnoid hemorrhage. The objective of this study was to compare the clinical outcome of patients with CV treated by 2 endovascular procedures: intra-arterial nimodipine angioplasty (IANA) and balloon angioplasty (BA). Between 2008 and June 2011, we performed 22 IANA and 8 BA in 30 patients. The mean age was 44 years and 60% was female. In 17 patients, the treatment was clipping, whereas 13 underwent coil treatment. The CV was severe in 63%, moderate in 30%, and mild in 7%. Good outcome between 2 groups was similar (P = .36). The clinical outcome according to the subgroups of CV severity and modality treatment was equivalent (P = .22). Mortality at 3 months was 16% and 20% at 1 year. We did not find differences in the clinical outcome despite the fact that both techniques produce adequate angiographic resolution of CV.

Asymptomatic carotid rete mirabile and contralateral carotid agenesis: a case report.

Carotid rete mirabile (CRM) is a physiological network between the external carotid artery (ECA) and internal carotid artery (ICA) in lower mammals. It is a transdural arterial network centered at the parasellar area, in anatomical localization of intracavernous or petrous segment of ICA, associated with hypoplasia or absence of the cervical or petrous segment of ICA. It clinically presents as hemorrhagic or ischemic cerebrovascular disorder. Carotid rete mirabile have an angiographic frequency of 0.01%. The authors present a new case of right ICA agenesis supported by primary collateral channels associated with left hypoplasic ICA and CRM. It is an unusual entity and we highlight the role of CRM in cerebral hemodynamic in this asymptomatic vascular patient. Our aim is detail the angiographic features and diagnosis criteria of CRM.

Sinus pericranii: case report.

Sinus pericranii (SP) is an abnormal communication between the intracranial and extracranial venous drainage pathways. Treatment of this condition has mainly been recommended for aesthetic reasons and prevention of hemorrhage. The authors report a conservative treatment for the potentially lethal complications.

Management of direct carotid-cavernous sinus fistulas with the use of ethylene-vinyl alcohol (Onyx) only: preliminary results.

OBJECT: So-called direct carotid-cavernous fistulas (CCFs) are commonly treated by detachable balloons or coils to occlude the shunt while sparing the carotid artery. Liquid embolic agents have been rarely used, and in particular, to the authors' knowledge, the use of Onyx as the sole agent has never been reported in an indexed publication. METHODS: The authors describe a case series of 5 patients with posttraumatic CCF in whom embolization with Onyx was prospectively used as the sole strategy of management. RESULTS: Complete occlusion was obtained at the end of the procedure in 4 cases, and the lesion in the remaining patient subsequently occluded at the 6-month follow-up evaluation. CONCLUSIONS: As endovascular techniques for treatment of direct CCFs continue to evolve, this novel approach with Onyx as the sole embolic material seems promising in treating these lesions.