Journal of vascular and interventional neurology最新文献

Purpose: Head and neck arteriovenous malformation (AVM) and fistulae treatment without reflux and with nidal penetration are challenging. We describe a case series including adult and pediatric patients utilizing a specific two-microcatheter technique using Onyx with strategic embolization of small feeding branches prior to dominant branch embolization. We aim to demonstrate the safety and efficacy of this technique.

Methods:

Patient selection: Head and neck vascular malformation cases were reviewed from 2010 to 2017. 11 patients between 2010 and 2017 were treated with serial embolization along with Onyx embolization utilizing a two-microcatheter technique. Five patients had cerebral AVMs, three had dural arteriovenous fistulae, two had mandibular AVMs, and one had a posterior neck AVM. Vascular anatomy, location, and procedural details were recorded.

Technique: During procedures 1-4, smaller arterial feeders were embolized first to maximally decrease the intranidal pressure at the time of the embolization of the major residual feeder. The dominant residual feeder was then embolized using two catheters. Coils followed by Onyx were initially deployed through the proximal catheter to form a dense plug. The plug was allowed to solidify for 30 min. Aggressive embolization of the nidus was then performed through the distal catheter.

Results: All 11 patients had excellent treatment results with complete (6) or near-complete (5) obliteration of the vascular malformation nidus. No procedural complications were noted, specifically no strokes, hemorrhages, or unintentionally retained catheter fragments occurred.

Conclusion: AVMs and fistulae are challenging to treat. A two-microcatheter technique for Onyx embolization with prior embolization of smaller arterial feeders is a safe and efficacious treatment option. This technique allows for maximal nidus penetration while minimizing the risk of nontarget embolization/reflux. In all cases, we achieved excellent results with complete or near-complete obliteration of the vascular malformation nidus.

An anomalous origin of the right vertebral artery is rare. The left vertebral artery from the aortic arch is where most of the anomalies occur. The next is an origin of the right vertebral artery from the right common carotid artery in association with the aberrant right subclavian artery. However, independent anomalous origin of the right vertebral artery from the right common carotid artery has not been well known in the previous literature. We present this anomaly, and able to understand the mechanism of the occurrence by embryological knowledge. Failure of involution of the fourth segmental artery and the ductus caroticus remaining are associated with this anomaly. To understand this, an aberrant may be helpful to avoid injury of the vertebral artery when performing the surgical procedures and catheterization.

Objective: To assess the effectiveness of cilostazol, a selective inhibitor of phosphodiesterase type III, in preventing cerebral ischemia related to cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH).

Methods: A total of six clinical studies met the inclusion criteria and were included in the meta-analysis. We calculated pooled risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. The primary endpoint was cerebral ischemia related to vasospasm. Secondary endpoints were angiographic vasospasm, new cerebral infarct, mortality, and death or disability at the final follow-up.

Results: A total of 136 (22%) of 618 subjects (38 and 98 assigned to cilostazol and control treatments, respectively) with SAH developed cerebral ischemia related to vasospasm. The risk of cerebral ischemia related to vasospasm was significantly lower in subjects assigned to cilostazol treatment (RR 0.43; 95% CI 0.31-0.60; p< 0.001). The risks of angiographic vasospasm (RR 0.67, 95% CI 0.54-0.84, p< 0.001 ) and new cerebral infarct (RR 0.37, 95% CI 0.24-0.57, p< 0.001) were significantly lower in subjects assigned to cilostazol treatment. There was a significantly lower rate of death or disability in subjects assigned to cilostazol treatment at follow-up (PR 0.55, 95% 0.39-0.78, p = 0.001).

Conclusion: The reduction in rates of cerebral ischemia related to vasospasm and death or disability at follow-up support further evaluation of oral cilostazol in patients with aneurysmal SAH in a large randomized clinical trial.

Background: Thrombectomy has become established as a successful treatment strategy for ischemic stroke, and consequently, more patients are undergoing this procedure. Due to comorbid conditions, chronic disease states, and advanced age, many patients have anatomy which complicates revascularization, specifically difficult aortic arch anatomy, or tortuous common and internal artery anatomy, or both.

Methods: In the present study, these unfavorable anatomic parameters were analyzed for 53 patients undergoing acute thrombectomy for ischemic stroke. Statistical analysis was performed and the outcome TICI scores were compared. 26 of the patients analyzed had features of difficult femoral access.

Results: Difficult arch anatomy was associated with unsuccessful revascularization (p = 0.03, Fisher's exact) with only 53% of patients with this feature having favorable TICI scores. Difficult common carotid access was also associated with unsuccessful revascularization (p = 0.004, Fisher's exact) with 38% success. There was a trend toward significance for unsuccessful revascularization for difficult internal carotid artery access (p = 0.06, Fisher's exact).

Conclusion: Any combination of the aforementioned anatomic parameters was associated with the decreased success of treatment which was an independent predictor in multivariate analysis (p = 0.009). As difficult access anatomy is commonly encountered in patients undergoing emergent thrombectomy, it is important for the treating physician to be prepared and to adapt access strategies to increase the likelihood of successful revascularization.

The TNF-α antagonists are the drugs used for the treatment of ulcerative colitis (UC). Nontraumatic convexity subarachnoid hemorrhage is an infrequent nonaneurysmal subtype of subarachnoid bleeding caused mainly by reversible cerebral vasoconstriction syndrome (RCVS), cerebral amyloid angiopathy, and posterior reversible encephalopathy syndrome (PRES). We present a 26-year-old female patient with a diagnosis of UC taking Adalimumab. She received her last doses the same day she was admitted to our hospital for an acute severe UC exacerbation. Steroids were added to the treatment. Five days after admission she presented a thunderclap headache with photophobia, nausea, and vomiting. An MRI was performed showing left frontal convexity subarachnoid hemorrhage and hyperintense lesions on T2-weighted and FLAIR sequences located in both occipital lobes, left cerebellar hemisphere, and brainstem. Digital angiography was unremarkable. Adalimumab was discontinued but persisted on treatment with steroids. The patient evolved with complete resolution of her symptoms and was discharged with a normal neurological exam. Two months later, she was asymptomatic and her MRI revealed superficial siderosis secondary to cSAH with resolution of white matter hyperintensities. Convexity subarachnoid hemorrhage in our patient could be secondary to PRES or to RCVS. Analogous MRI findings can be observed in both syndromes, along with similar clinical and angiographic findings. This suggests that both conditions may reflect different manifestations of the same pathology, in which vascular tone and endothelial dysfunction play a major role. To our knowledge, this is the first report of a patient with severe UC and convexity subarachnoid hemorrhage associated with Adalimumab.

Background: Recognition of stroke warning signs and risk factors reduces prehospital delay and increases stroke survival. The goal of this study was to evaluate the public knowledge of stroke warning signs and risk factors in a rural area in Central Pennsylvania.

Materials and methods: In this study, the 2016 Sullivan County Health Fair attendees in central Pennsylvania answered a structured close-ended multiple choice questionnaire about stroke warning signs and risk factors. Further questions were asked about their reaction to acute stroke, the source of their stroke knowledge, and if they had personally known a stroke victim.

Results: Out of 163 respondents, 85.3% selected ≥3 (out of 4) correct stroke warning signs and 71.8% of respondents selected ≥3 (out of 5) correct stroke risk factors. Regarding the wrong stroke warning signs, 34.4% mentioned neck pain followed by chest pain (33.1%). Identification of ≥1 (out of 3) wrong stroke warning signs were significantly lower among the respondents of postgraduate level education in comparison with other literacy groups. 95.7% of respondents chose "call 911 immediately" in response to an acute stroke. A relative with a history of stroke was the most cited source of information. Multivariate analysis found that a high level of education increases odds of recognition of ≥3 correct stroke risk factors (0.21; 95% confidence interval, 0.09-0.61). Knowing anyone with stroke was associated with an awareness of the life-threatening nature of stroke (r = 0.21, P < 0.01).

Conclusion: Respondents' recognition of stroke warning signs was favorable. About 85% of respondents recognized at least three stroke warning signs with no significant age and literacy effect. Our results provide evidence that the subjects most at risk of stroke are those with the least awareness of stroke risk factors.

Objective: We report a case of dural arteriovenous fistula (dAVF) presenting as isolated cerebral aqueduct hemorrhage.

Result: A 73-year-old man with a history of hypertension and chronic alcoholism presented with altered mental status and gait difficulties, bilateral fronto-occipital headaches, and intermittent dizziness. He had bilateral upward gaze restriction. Computerized tomography scan showed hyperdensity in the cerebral aqueduct and dilation of the lateral and third ventricles. The diagnostic angiogram demonstrated dAVF with arterial feeders from the cavernous segment of the left internal carotid artery and venous drainage into left transverse and sigmoid venous sinus.

Conclusion: Underlying dAVF should be considered in patients with isolated cerebral aqueduct hemorrhage.