Journal of vascular and interventional neurology最新文献

Introduction: Sympathetic activity from the superior cervical ganglion (SCG) has been shown to cause cerebral hypoperfusion in swine, similar to that seen with clinical cerebral vasospasm. Although the mechanism of such perfusion deficit has been speculated to be from pathologic cerebral vasoconstriction, the extent of sympathetic contribution to vasoconstriction has not been wellestablished.

Objective: We aimed to demonstrate that SCG stimulation in swine leads to significant cerebral vasoconstriction on digital subtraction angiography (DSA). Additionally, we aimed to show that inhibition of SCG can mitigate the effects of sympathetic-mediated cerebral vasoconstriction.

Methods: Five SCGs were surgically identified in Yorkshire swine and were electrically stimulated to achieve sympathetic activation. DSA was performed to measure and compare changes in cerebral vessel diameter. Syngo iFlow was also used to quantify changes in contrast flow through the cerebral and neck vessels.

Results: SCG stimulation resulted in 35-45% narrowing of the ipsilateral ascending pharyngeal, anterior middle cerebral and anterior cerebral arteries. SCG stimulation also decreased contrast flow through ipsilateral ascending pharyngeal, internal carotid and anterior cerebral arteries as seen on iFLow. These effects were prevented with prior SCG blockade. Minimal vessel caliber changes were seen in the posterior cerebral, posterior middle cerebral and internal carotid arteries with SCG stimulation.

Conclusion: SCG stimulation results in significant luminal narrowing and reduction in flow through various intracranial arteries in swine. The results of sympathetic hyperactivity from the SCG closely models cerebral vasoconstriction seen in human cerebral vasospasm. SCG inhibition is a potential promising therapeutic approach to treating cerebral vasospasm.

Background/objective: Various strategies have been implemented to reduce acute stroke treatment times. Recent studies have shown a significant benefit of acute endovascular therapy. The JFK Comprehensive Stroke Center instituted Code Neurointervention (NI) on May 1, 2014 for the purpose of rapidly assembling the NI team and rapidly providing acute endovascular therapy.

Design/methods: We performed a retrospective analysis of all patients who had Code NI (Code NI group) called from May 1, 2014 to July 30, 2018 and compared them to patients who underwent acute endovascular treatment prior to initiation of the code (pre-Code NI group) between January 2012 and April 30, 2014. The following parameters were compared: door to puncture (DTP) and door to recanalization (DTR) times, as well as preprocedure NIHSS, 24-hour postprocedure NIHSS, and 90-day modified Rankin scores.

Results: There were 67 pre-Code NI patients compared to 193 Code NI patients. Mean and median DTP times for pre-code NI vs Code NI patients were 161 minutes(mins) vs 115mins (p<0.0001, 31.76-58.86) and 153mins vs 112mins (p <0.0001), respectively. Mean and median DTR times were 220 mins vs 167mins (p <0.0001, 37.76-69.97) and 225mins vs 171mins (p <0.0001). Mean pre-procedure NIHSS was 16 for both groups while 24 hours post procedure NIHSS was 10.6 vs 10.8 (p =.078, 1.8-2.38). Mean 90 day mRS was 2.15 vs 1.65 (p=0.036, 0.32-0.96).

Conclusion: Institution of Code NI significantly improved DTP and DTR times as well as mRS at 3-months postprocedure. Rapid assembly of the NI team, rapid availability of imaging and angiography suite, and streamlining of processes, likely contribute to these differences. These lessons and more widespread institution of such codes will further aid in improving acute stroke care for patients.

Objective: Flow diversion using devices such as the "pipeline" stent is now a common treatment for unruptured intracranial aneurysms. Though much is known about the efficacy of the device, less is reported regarding potential side effects. In this study, we report the frequency and characteristics of the "post-pipeline headache."

Methods: We prospectively enrolled a cohort of 222 patients who underwent pipeline stenting for the treatment of intracranial aneurysm between 2015 and 2018. A follow-up telephone survey was conducted with a mean 21.6 months postprocedure evaluating postprocedure headaches and previous headache history. A post-pipeline headache was defined as a new headache or pain distinct from their prior headache syndrome. Information was collected regarding patient demographics, headache characteristics, headache history, and whether symptoms were ongoing. Logistic regression was used to determine factors associated with post-pipeline headache and the risk of long-term headache persistence.

Results: Eighty-eight individuals were reached by phone for follow-up; 48 (55%) of whom reported a new headache postprocedure. Patients experiencing post-pipeline headache were more likely to be young (OR 0.9; 95% CI: 0.85-0.94) and have a history of prior headaches (OR 2.4, 95% CI: 1.02-5.81). Associated motor (OR 6.1; 95% CI: 1.19-31.47), cognitive (OR 7.0; 95% CI: 081-60.33), visual (OR 5.4; 95% CI: 1.05-27.89), and vestibular (OR 4.8; 95% CI: 1.14-20.23) symptoms were associated with ongoing headache.

Conclusions: Post-pipeline headache is common, particularly in younger individuals with prior headache history, and has distinctive features. Symptoms can remit over time; however, two-thirds experience ongoing headaches, particularly those with associated migrainous features.

Background: The natural history and epidemiological aspects of traumatic injury of major cerebral venous sinuses are not fully understood. We determined the prevalence of traumatic injury of major cerebral venous sinuses and impact on the outcome of patients with traumatic brain injury, and/or head and neck trauma.

Methods: All the patients who were admitted with traumatic brain injury or head and neck trauma were identified by ICD-9-CM codes from the National Trauma Data Bank (NTDB), using data files from 2009 to 2010. NTDB represents one of the largest trauma databases and contains data from over 900 trauma centers across the United States. Presence of thrombosis, intimal tear, or dissection (traumatic injury) of major cerebral venous sinuses was identified in these patients by using Abbreviated Injury Scale predot codes. Admission Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), In-hospital complications, and treatment outcome were compared between patients with and without traumatic injury of major cerebral venous sinuses.

Results: A total of 76 patients were identified with traumatic injury of major cerebral venous sinuses among 453,775 patients who had been admitted with head and neck trauma. The rate of penetrating injury was higher among patients with traumatic injury of major cerebral venous sinuses (11.8% versus 2.5%, p = 0.0001). The patients with traumatic injury of major cerebral venous sinuses had a significantly higher rate of intracranial hemorrhage in comparison to patients without traumatic injury of major cerebral venous sinuses. The odds of in-hospital mortality remained significantly higher for patients with traumatic injury of major cerebral venous sinuses after adjusting for age, gender, admission GCS score, ISS injury type, and presence of intracranial hemorrhage [odds ratio (OR): 6.929; 95% confidence interval (CI) 1.337-35.96; p < 0.020]. The odds of discharge to nursing home remained higher for patients with traumatic injury of major cerebral venous sinuses after adjusting for potential confounders (OR: 1.8401; 95% CI 1.18-2.85, p < 0.0065).

Conclusion: Although infrequent, traumatic injury of major cerebral venous sinuses in head and neck trauma is associated with higher rates of in-hospital mortality and discharge to a nursing home.

Background: Upright posture intolerance can be seen in a variety of diseases but the current methodology is not quantifiable and limits the ability to identify response to treatment.

Methods: A standard questionnaire was developed to assess the following aspects of upright posture tolerance: (1) How long can you stand straight without any support? (2) Do you feel any sense of sickness when you sit or lie down after standing? (3) How long do you have to wait before you are comfortable standing again after you have stood straight? (4) How effectively and fast can you get up from sitting or lying position to stand straight? and (5) rate the ability to perform activities on a standard vertical visual analog scale between 100 (can do everything) and 0 (cannot do anything). We tested the ability of the questionnaire in four patients to identify various aspects of upright posture intolerance.

Results: The questionnaire was administered to four patients who reported upright posture intolerance. The patients with either intracranial hypotension syndrome, postural hypotension, or Klippel-Feil syndrome reported less than optimal performance in four of five components of the questionnaire. The patient with vertebrobasilar ischemia reported less than optimal performance in two of five components.

Conclusions: A new questionnaire is developed for self-administration to identify various components of upright posture intolerance and detect response to treatment.

Background: Symptomatic vasospasm (sVSP) is a common complication during the course of aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate the efficacy and accuracy of transcranial Doppler ultrasound (TCD), performed within the first 3 days of aSAH to predict the development of sVSP.

Methods: We performed a retrospective analysis of our institutional prospectively collected database of patients with aSAH. Patients with aSAH and World Federation of Neurosurgical Societies (WFNS) grades I-III were included in the analysis. A receiver operating characteristic (ROC) curve was generated to determine cut-off values for mean flow velocities (MFVs) in the middle cerebral artery (MCA) and anterior cerebral artery (ACA) bilaterally to predict sVSP.

Results: Fifty-one patients were included in the study. Mean age was 49.8 ± 10.2 years, and 84.3% (43 patients) were women. The accuracy of measured MFVs to predict sVSP was 0.79 [95% confidence interval (CI), 0.69-0.89] and 0.77 (95% CI, 0.64-0.91) for the MCA and the ACA, respectively. In the MCA, an MFV ≥ 74 cm/s was significantly associated with a six-fold increased risk of sVSP, achieving sensitivity greater than 70%. In the ACA, an MFV ≥ 64 cm/s was significantly associated with a nine-fold increased risk of sVSP.

Conclusion: Early TCD evaluation of MFVs in the MCA and ACA is a useful tool to predict the development of sVSP in patients with acute aSAH.

We describe a variant where the A2 segment of one anterior cerebral artery anastomose distal to the origin of the anterior communicating artery with the A2 segment of the contralateral anterior cerebral artery. The anastomoses are seen without any hypoplasia or aplasia of A2 segments prior to anastomoses unlike azygous or bihemispheric anterior cerebral artery. The anastomoses occur prior to bifurcation of the anterior cerebral artery into pericallosal and callosomarginal arteries.

Background: Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure of unknown etiology. Unilateral or bilateral transverse sinus (TS) or transverse-sigmoid junction stenosis is present in about 30%-93% of these patients. There is an ongoing debate on whether venous sinus stenosis is the cause of IIH or a result of it. The subset of IIH patients who continue to have clinical deterioration despite maximum medical therapy is termed as "refractory IIH." Traditionally, cerebrospinal fluid diversion surgeries (ventriculoperitoneal shunt and lumboperitoneal shunt) and optic nerve sheath fenestration (ONSF) were the mainstays of treatment for refractory IIH. In the last decade, venous sinus stenting (VSS) has emerged as a safe and effective option for treating refractory IIH patients with venous sinus stenosis. Through this study, we want to share our experience with venous stenting in refractory IIH patients with venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg).

Methods: Retrospective chart review of all the patients diagnosed with refractory IIH who underwent VSS or angioplasty at our comprehensive stroke center from November 2016 to March 2019.

Results: A total of seven refractory IIH patients underwent VSS or angioplasty within the specified period. The mean age was 39 years. Eighty-five percent of the patients were women (n = 6). The mean body mass index (BMI) was 37 kg/m². Headache was the most common symptom (85%, n = 6) followed by transient visual obscurations (71%, n = 5) and pulsatile tinnitus (57%; n = 4). All patients had papilledema. Fifty-seven percent of patients (n = 4) had impaired visual field. Mean lumbar opening pressure was 40.6 cm H₂O (SD = 9.66; 95% CI = 33.5-47.7). All patients were on maximum doses of acetazolamide ± furosemide. Six patients (85%) had dominant right transverse-sigmoid sinus. Fifty-seven percent of the patients had severe right transverse ± sigmoid sinus stenosis (n = 4) and the rest (43%) had bilateral TS stenosis (n = 3). Prestenting mean trans-stenosis pressure gradient was 18 mm Hg (SD = 6.16; 95% CI = 13.43-22.57). Six patients (85%) were treated with TS stenting and one (15%) with only angioplasty. Poststenting mean trans-stenosis pressure gradient was 4.8 mm Hg (SD = 6.6; 95% CI = -0.1-9.7). All patients were able to come off their medications with significant improvement in neurological and ophthalmological signs and symptoms. No procedure-related complications occurred.

Conclusion: TS stenting ± angioplasty is a safe and effective means of treating refractory IIH with venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg).

Objective: The second-generation pipeline embolization device (PED), flex, has improved opening and resheathing ability compared to the first-generation classic PED device. A previously reported single-institutional study suggests that the PED flex devices are associated with lower rates of complications. However, there was limited discussion regarding the complication rate with respect to microcatheter choice for PED delivery and deployment. The present study aims to evaluate outcomes of aneurysm treatment with PED flex versus classic along with the Phenom microcatheter versus Marksman microcatheter.

Methods: A retrospective, IRB-approved database of all patients who received a PED classic or PED flex device between January 2012 and July 2018 was analyzed. Microcatheter choice, patient demographics, medical comorbidities, aneurysm characteristics, treatment information, and outcome data were analyzed using univariate analyses.

Results: A total of 75 PED procedures were analyzed. There was no significant difference in major complications between the PED classic and PED flex. However, those treated using the Marksman microcatheter were more likely to have a major complication (periprocedural hemorrhage or ischemic event; 16.6% vs. 0%, p = 0.0248) than those treated with the Phenom microcatheter. Within the PED flex cohort, all major complications were associated with the Marksman microcatheter (p = 0.0289).

Conclusions: The present study does not replicate significantly fewer complications with PED flex but demonstrates a significant reduction in complications with the Phenom microcatheter. Ultimately, this suggests multiple factors are involved in achieving positive outcomes and low complication rates in PED treated unruptured cerebral aneurysms.

Delayed cerebral ischemia (DCI) due to cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) has long been recognized as a major source of morbidity and mortality. Early detection of cerebral vasospasm and identification of patients who are likely to become symptomatic is crucial to guide aggressive medical and/or endovascular interventions. Magnetic resonance imaging using arterial spin-label (ASL) is a noninvasive mean for assessing cerebral blood flow and is based on direct magnetic labeling of arterial blood water protons. The diagnostic role of ASL in acute ischemic stroke, epilepsy, and neurodegenerative disorders has been explained in multiple studies but its ability to predict vasospasm in aSAH has not been published before. The purpose of this study is to highlight the diagnostic implications of different perfusion patterns of ASL in patients with aSAH which can be utilized to prevent DCI in such patients when other commonly used modalities are not available, contraindicated, or fail to detect vasospasm.