Comparative analysis of aneurysm volume by different methods based on angiography and computed tomography angiography.

Endovascular treatment and prognosis of intracranial aneurysms are based on size and volume, which demand more accurate neuroimaging techniques. Aneurysm volume calculation is important to choose endovascular treatment modalities and packing density calculation. Of all these methods, it remains unknown which one is the most accurate to calculate aneurysm volume. The objective of this study is to compare the accuracy of three angiography-based versus three tomographic-based methods which calculate aneurysm volume. A retrospective study which included patients with ruptured and unruptured cerebral aneurysms diagnosed by angiogram and computed tomography angiography (CTA) was done. The accuracy of each method was assessed with an ellipsoid glass model of known volume, which helped us to adjust variation in volumetric measurements done with AngioSuite© and AngioCalc© softwares (based on angiographic and tomographic images), 3D-rotational angiography and 3D-CTA (tridimensional computed tomography angiography), based on measurements of diameters such as maximal width and maximal height. Descriptive statistics, ANOVA for repetitive samples and t test were used. We included 89 patients (126 saccular intracraneal aneurysms). AngioSuite© software (angiography-based) showed more accuracy compared to other methods in our control model. The geometric system (AngioCalc) based on CTA images was statistically different from all other methods studied. AngioCalc (CTA-based) demonstrated a significant difference compared with other methods hence, it may overestimate volume measurements. AngioSuite

[Endovascular management of cavernous sinus dural fistulas]. / Manejo endovascular de las fistulas durales al seno cavernoso.

OBJECTIVE: Describe the outcomes of patients diagnosed with indirect carotid-cavernous fistula treated by endovascular methods. DESIGN: A retrospective case series. PARTICIPANTS: Twelve patients with dural cavernous sinus fistula with important ophthalmologic involvement admitted and treated at the National Institute of Neurology and Neurosurgery between February 1990 and January 2005. INTERVENTION: Patients were managed by endovascular embolization for all fistulas. OUTCOME MEASURES: Angiographic controls to 24 hours and at 6 and 12 months were performed. RESULTS: 67 % were female and 33 % male. The mean age was 44 years. 67 % were spontaneous and 33% of traumatic origin. All patients had eye involvement with proptosis (92%) and involvement of the oculomotor nerve (67%). Headache and pulsatile tinnitus were not frequent ophthalmologic data. All were diagnosed by cerebral angiography, 33 % were type C, type D 67 %, and none of the type B classification Barrow. In 17 % of cases the distal arterial robbery showed severe. Predominance of anterior and superior venous drainage in 83 % and 42 % of cases occurred respectively. The surgical approach was arterial in 84% of cases, while in 17 % venous through the superior ophthalmic vein. Cyanoacrylate embolization material was used in 58 % of the cases, as it was associated with the use of removable ball with polyvinyl alcohol particles in 16 % in of venous approach cases. 17% detachable coils were utilized. There were no complications. After angiographic controls at 24 hours 100% occlusion was seen in patients treated with cyanoacrylate (58%) (p = 0.03). The remaining 42% were prescribed maneuver of manual compression. At 12-months angiography all patients had 100% occlusion of the carotid-cavernous fistula. CONCLSUIONS: This is the world's second largest series with indirect carotid-cavernous fistulas treated after trauma. 100 % of cases were cured with the use of a transarterial-controlled approach and N-butyl-cyanoacrylate after long-term observation.

[Anatomic variations of the internal carotid artery: implications for the neurologic endovascular therapist]. / Variaciones anatomicas de la arteria carotida interna: implicaciones para el terapista endovascular neurologico.

Tortuosity of the cervical segment of the internal carotid artery (ICA) can hinder navigation intravascular devices for treating intracranial aneurysms and even complex ICA access techniques can fail. Variations in the course of the internal carotid artery are known as coiling, kinking or tortuosity of the vessel. Such failures have clinical relevance. During endovascular procedures these anomalies difficult the intravascular surgical procedure. A potential alternative is the reconstruction of these anatomic anomalies of the carotid artery using neuro-interventional methods. We present a practical review of the literature.

Changes in blood and renal function in patients after cerebral digital subtraction angiography.

Objective: Describe the incidence of contrast-induced acute renal injury (CI-AKI) and the changes in hematocrit in a cohort of patients undergoing elective cerebral digital subtraction angiography (DSA). Methods: In this prospective study, patients undergoing cerebral DSA were assessed for hematocrit level and CI-AKI risk factors before the procedure and for developing CI-AKI 72 h after exposure to the contrast media. Results: Among 215 patients (109 men, mean age 36.6 years). The most frequently found CI-AKI risk factor was hypertension. There were no cases of permanent renal impairment after 14 days. Significant changes were observed in hematocrit (45.7 ± 4.9, vs. 44.5 ± 4.6, p = 0.001), estimated creatinine clearance (129.7 ± 48.3, vs. 123.1 ± 40.5, p = 0.002), and serum creatinine (0.72 ± 0.19, vs 0.74 ± 0.18, p = 0.031). The mean change in serum creatinine 72 h after contrast administration was +0.27 ± 0.10 mg/dL (p < 0.05). Conclusions: The incidence of CI-AKI after elective cerebral DSA was 1.4%. A significant decrease in hematocrit was observed up to 72 h after the procedure.

[Endovascular approach in the management of intracranial aneurysms. Part 1: basic concepts and devices]. / Perspectiva endovascular en el manejo de los aneurismas intracraneales. Parte 1: Conceptos básicos y dispositivos.

Neurological endovascular therapy is a discipline that has shown effectiveness and safety in the management of intracranial aneurysms, however recanalization persists as one of the most important obstacles to overcome. Precise knowledge of the anatomy and hemodynamics of the aneurysm and the parent artery as well as currently available endovascular devices, are decisive in the analysis and to design a specific treatment plan for each case. In this manner we ensure, as long as possible, success and durability of the treatment.

[Endovascular approach in the management of intracranial aneurysms. Part 2: indications and therapeutic strategy]. / Perspectiva endovascular en el manejo de los aneurismas intracraneales. Parte 2: Indicaciones y estrategia terapéutica.

The success and stability of the occlusion of intracranial aneurysms can be achieved after an adequate conceptualization and implementation of current endovascular techniques, which in turn should be based on knowledge of available devices and the analysis of the specific characteristics the aneurysm and its parent artery to what we called aneurysmal complex.

[Traumatic arteriovenous pial fistula masquerading as a carotid-cavernous fistula: an uncommon disorder with an unusual presentation]. / Fístula arteriovenosa pial traumática que simula una fístula carotidocavernosa: una enfermedad infrecuente con una presentación excepcional.

Traumatic intracranial pial arteriovenous fistulae are infrequent lesions. Their cardinal signs have been related to mass effect and hemorrhage, but their clinical manifestations due to venous retrograde flow into ophthalmic veins has never been described. This phenomenon is usually seen in dural arteriovenous fistula draining to the cavernous sinus or carotid-cavernous sinus fistula.A traumatic intracranial pial arteriovenous fistula arising from the supraclinoid internal carotid artery in a young patient was revealed by aggressive behavior and ophthalmologic manifestations. The endovascular management included the use of coils, stent, and ethylene-vinyl alcohol with transient balloon occlusion of the parent vessel.

The 2020 research pandemic: A bibliometric analysis of publications on COVID-19 and their scientific impact during the first months.

BACKGROUND: The outbreak of COVID-19 has created a landslide of publications, from different sources and unequal impact. We considered that the first 3 months are crucial to understand how knowledge has been generated by performing a bibliometric analysis, including the citations to these articles to guide researchers in exploring this field, and to evaluate the relationship between confirmed COVID-19 cases and deaths with the number of papers per country. METHODS: Scientific publications were obtained from PubMed (January-March 2020) and their citations during the first 6 months retrieved from the Scopus database. An analysis of the number of papers by country, approach (type and category of publication), and impact was made. A multiple linear regression model was implemented to analyze the correlation between the number of publications and confirmed cases and deaths. RESULTS: A total of 2,530 publications were analyzed with 59,104 citations (23.4 citations/article), written by authors from 67 countries. China was the country with more publications (988, 39%) and more citations (36,416, 63%) followed by the United States with 423 articles (16.7%) and 7,458 citations (12.6%). The coauthorship network identified 10,756 authors. According to the multivariate analysis, both confirmed cases and deaths were significantly correlated with the number of publications per country (corrected by population size and gross domestic product). CONCLUSION: The correlation with the number of publications suggests that cases and deaths had some impact on the medical literature, reflecting how rapidly the scientific community has been on the frontline in the fight against COVID-19.

Knowledge of ischemic stroke among a Mexico City population.

INTRODUCTION: Knowledge of risk factors (RF) and warning signs of stroke by the general population is fundamental to implement efficient preventive measures and provide timely treatment. The objective of this study was to assess this knowledge in a sample population of Mexico City. METHODS: Personal interview was conducted in a multifamily building complex in Mexico City. The questionnaire included sociodemographic and comorbidity factors. Knowledge was determinated according to the number of correct answers. Chi-square and Wilcoxon rank tests were performed and significant variables were included in a multivariate logistic regression model using level of knowledge as the dependent variable. RESULTS: A total of 330 subjects were interviewed. Of the respondents, 66.7% named one RF associated with ischemic stroke, whereas only 12.1% identified 3 or more; one warning sign was identified by 36.7% and only 2.1% identified 3 or more. The factors associated with knowledge of RF were history of hypertension, educational level, and family history of ischemic stroke. Educational level and a family history of stroke were also associated with knowledge of warning signs. DISCUSSION: A Family history of ischemic stroke was the most important way to receive information about RF and warning signs of ischemic stroke. The study shows the need for informing the public about prevention and early detection of ischemic stroke.

A Pilot Study of Facial Nerve Stimulation on Cerebral Artery Vasospasm in Subarachnoid Hemorrhage Patients.

BACKGROUND: The objective of this pilot study was to assess the safety and efficacy of VitalFlow stimulation in aneurysmal subarachnoid hemorrhage (aSAH) patients with vasospasm for the purpose of guiding the design of larger, controlled studies in vasospasm patients, a largely untreated condition [1]. METHODS: Six patients with angiographic vasospasm developing post-aSAH were treated with VitalFlow stimulation. Digital subtraction angiograms were obtained at the time of diagnosis (baseline) and then 30 minutes post-stimulation. A single 2-minute period of stimulation was delivered to the patients using parameters previously shown to be safe, tolerable, and effective at increasing cerebral blood flow (CBF) in healthy volunteers. RESULTS: VitalFlow stimulation improved tissue perfusion as assessed by parenchymography and reversed the constriction of vasospastic arteries. Two patients had only partial improvement and so were treated with intraarterial nimodipine after VitalFlow stimulation, whereas four patients had complete resolution of the vasospasm after VitalFlow stimulation per the treating neuroendovascular surgeon's evaluation. Clinical examination showed improvement in Hunt and Hess Scale scores assessed post-stimulation. CONCLUSIONS: Non-invasive magnetic stimulation of the facial nerve with the VitalFlow stimulator appears to be a safe and effective means to reverse angiographic vasospasm in aSAH patients. Clinical Impact: This study provides Class IV evidence that non-invasive magnetic stimulation of the facial nerves reduce angiographic vasospasm in aSAH patients.

Definition of the key target volume in radiosurgical management of arteriovenous malformations: a new dynamic concept based on angiographic circulation time.

OBJECT: The cumulative experience worldwide indicates complete radiosurgical obliteration rates of brain arteriovenous malformations (AVMs) ranging from 35 to 90%. The purpose of this study was to propose a strategy to increase the obliteration rate for AVMs through the dynamic definition of the key target volume (KTV). METHODS: A prospective series of patients harboring an AVM was assessed using digital subtraction angiography in which a digital counter was used to measure the several stages of the frame-by-frame circulation time. All the patients were analyzed using dynamic measurement planning to define the KTV, corresponding to the volume of the shunt with the least vascular resistance and the earliest venous drainage. All patients underwent catheter-based angiography, a subgroup was additionally assessed by means of a superselective catheterization, and among these a further subgroup received embolization. The shunts were also categorized according to their angioarchitectural type: fistulous, plexiform, or mixed. The authors applied the radiosurgery-based grading system (RBGS) as well to find a correlation with the obliteration rate. RESULTS: This series includes 44 patients treated by radiosurgery; global angiography was performed for all patients, including dynamic measurement planning. Eighty-four percent of them underwent superselective catheterization, and 50% of the total population underwent embolization. In the embolized arm of the study, the pretreatment volume was up to 120 ml. In patients with a single treatment, the mean volume was 8.5 ml, and the median volume was 6.95 +/- 4.56 ml (mean +/- standard deviation), with a KTV of up to 15 ml. For prospectively staged radiosurgery, the mean KTV was 28 ml. The marginal radiation dose was 18-22 Gy, with a mean of dose 20 Gy. The mean RBGS score was 1.70. The overall obliteration rate was 91%, including the repeated radiosurgery group (4 patients), in which 100% showed complete obliteration. The overall permanent deficit was 2 of 44 patients, 1 in each group. CONCLUSIONS: Dynamic definition of the KTV might increase the obliteration rate, even in complex AVMs, allowing the treatment of smaller volumes off the recruitment vessels (pseudonidus). By using this technique, the authors avoided double-blind treatment, where the neurosurgeon does not know precisely which type of lesion he or she is irradiating and the interventionalist does not know why and what he or she is embolizing.

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.

Rupture of Persistent Primitive Trigeminal Artery-basilar Artery Aneurysm Managed with Stent-assisted Coiling.

Persistent primitive trigeminal artery (PPTA), a fetal carotid-basilar anastomosis, is the most common embryological vascular remnant persisting into adult age. However, reported cases associated with cerebral aneurysms are rare. A 33-year-old female presented with an extremely rare PPTA-basilar artery (PPTA-BA) aneurysm manifesting as subarachnoid hemorrhage. Computed tomography revealed subarachnoid bleeding in the prepontine cistern, and cerebral angiography disclosed a PPTA-BA aneurysm. The aneurysm was managed with stent-assisted coiling technique to achieve complete obliteration. The patient was discharged without neurological deficits 2 weeks later. At 6 months follow-up, the patient is doing well and has returned to her previous daily activities. PPTA-BA aneurysms usually present with cranial nerve palsy and sometimes with carotid-cavernous fistulae if they rupture. Their deep seating favors interventional management as a first option and this case illustrates the efficacy and safety of endovascular treatment. This case adds to the evidence that endovascular techniques are a safe and effective tool in managing aneurysms of the primitive trigeminal artery. Even in cases where the anastomosis itself is not preserved, the patient can be managed satisfactorily, provided that the patency of the basilar and the carotid artery are kept, like in our patient.

Persistent Primitive Trigeminal Artery Associated With Anterior Communicating Artery Aneurysm and Hypoplastic Vertebral Artery.

The persistent trigeminal artery is one of the presegmental arteries in the embryonic period; in some rare cases, it is associated with cerebral aneurysm but as a cause of subarachnoid hemorrhage (SAH) has not been described in the literature. We report a patient who presented a Fisher IV SAH associated with a ruptured intracranial aneurysm. The performed cerebral angiography demonstrated the presence of aneurysm in the anterior communicating artery associated to hypoplastic vertebral artery on the same side. We considered those finding coincidental. The coexistence of saccular aneurysm with anatomical variations in the intracranial vasculature is briefly discussed. It was managed by endovascular embolization. The patient returned to normal activities.

Endovascular Management of Intracranial Pial Arteriovenous Fistulas: Experience of Largest Series at a Single Center Over Six Years.

INTRODUCTION: Intracranial pial fistulas are an extremely uncommon type of vascular pathology consisting of one or multiple arterial connections to a single venous drainage channel without the presence of an intervening nidus. Due to its typical location and high-flow dynamics, its management is difficult and options include endovascular treatment and open surgical treatment. The arterial supply of these lesions is usually derived from pial or cortical vessels, and commonly such lesions are not localized in the dura mater. MATERIALS AND METHODS: Authors report the experience of consecutive ten cases managed at the Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez" of México extending from 2007 to 2012 with endovascular technique, constituting one of the largest series in the Western literature. DISCUSSION: Pial fistulas are associated with a poor natural history, and the selection of individualized therapeutic strategies can provide good outcomes. CONCLUSION: The neuroendovascular intervention is currently considered as safe, low cost, and effective management modality for such lesions.

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.

Carotid plaque inflammation detected by 18F-fluorodeoxyglucose-positron emission tomography. Pilot study.

OBJECTIVES: Inflammation is important in both the pathogenesis and outcome of atherosclerosis. Current imaging techniques provide anatomic data but no indication of plaque inflammation. We tested the hypothesis that plaque inflammation could be assessed in vivo by (18)FDG-PET and that plaque inflammation could increase the risk of recurrent vascular events and poor response to treatment in a pilot study. PATIENTS AND METHODS: Thirteen patients (median age 66.1 years [55-82 years]) with recent carotid territory TIA or ischemic stroke and internal carotid artery (ICA) stenosis > or =50% were studied. Angiography and (18)F-fluorodeoxyglucose-positron emission tomography ((18)FDG-PET) imaging were carried out in all patients. Treatment for carotid stenosis in each patient was selected by the attending physician and consisted in medical treatment, endarterectomy or stent placement. During 6 months of follow-up, the specific end points assessed were the occurrence of any stroke, death, or re-stenosis. RESULTS: Patients with symptomatic carotid atherosclerosis were imaged using (18)FDG-PET. Strong (18)FDG uptake (SUV> or =2.7) was seen in 11 of 13 (85%) carotid lesions. Among these patients two died during follow-up, 3 had recurrent non-fatal ipsilateral ischemic stroke and 1 patient who had undergone stenting had non-symptomatic re-stenosis in control studies. There was a significant correlation between the (18)FDG uptake and degree of ICA stenosis detected by angiography. CONCLUSION: Carotid atherosclerotic plaques contain a variable degree of inflammation which can be assessed in vivo by means of FDG and PET. The prognostic value of this marker is, however, still unclear and needs further study.

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.

A proposed classification for assessing rupture risk in patients with intracranial arteriovenous malformations.

BACKGROUND: Whether cerebral arteriovenous malformations (AVMs) should be treated remains an ongoing debate. Nevertheless, there is a need for predictive factors that assist in labelling lesions as low or high risk for future rupture. Our aim was to design a new classification that would consider hemodynamic and anatomic factors in the rapid assessment of rupture risk in patients with AVMs. METHODS: This was a retrospective study that included 639 patients with ruptured and unruptured AVMs. We proposed a new classification score (1-4 points) for AVM rupture risk using three factors: feeding artery mean velocity (Vm), nidus size, and type of venous drainage. We employed descriptive statistics and logistic regression analysis. RESULTS: A total of 639 patients with cerebral AVMs, 388 (60%) had unruptured AVMs and 251 (40%) had ruptured AVMs. Logistic regression analysis revealed a significant effect of Vm, nidus size, and venous drainage type in accounting for the variability of rupture odds (P = 0.0001, R2 = 0.437) for patients with AVMs. Based in the odds ratios, grades 1 and 2 of the proposed classification were corresponded to low risk of hemorrhage, while grades 3 and 4 were associated with hemorrhage: 1 point OR = (0.107 95% CI; 0.061-0.188), 2 point OR = (0.227 95% CI; 0.153-0.338), 3 point OR = (3.292 95% CI; 2.325-4.661), and 4 point OR = (23.304 95% CI; 11.077-49.027). CONCLUSION: This classification is useful and easy to use, and it may allow for the individualisation of each cerebral AVM and the assessment of rupture risk based on a model of categorisation.