Journal of vascular and interventional neurology最新文献

Aim: To evaluate the role and efficacy of the balloon angioplasty in intracranial atherosclerotic disease (ICAD) in patients who presented with acute stroke due to vessel occlusion and in patients with symptomatic disease despite optimum medical management.

Methods: From 2013 to 2016, a total of 39 patients (24 males and 15 females with a mean age of 64.5 years) underwent balloon angioplasty over a period of 2 years and 8 months in three different institutions in India. Maverick balloon catheter (Boston scientific) is used in all the patients. MRI brain with MR angiogram was done in all the patients prior to intervention. Twenty-three patients who had underlying severe ICAD presented with acute stroke due to vessel occlusion. Sixteen patients presented with symptomatic ICAD with recurrent ischemic attack due to the progressing underlying disease despite optimum medical management. Technical success, peri-procedural events, and clinical outcomes were documented for all the patients.

Results: Technical success (residual stenosis < 50%) was achieved in 37 cases. Extra cranial carotid stenting was required in 2 patients. In patients with acute stroke presentation (NIHSS score median of 16.5), adjuvant intravenous and intra-arterial tissue plasminogen activator were given in 8 and 3 patients, respectively, and mechanical thrombectomy (MT) with solitaire was used in 15 patients. Patients who underwent MT in acute stroke without ICAD were not included in the study. Reocclusion occurred in one patient who developed disabling stroke and one patient died of intra-cerebral hemorrhage. Thus, the mortality of this study is 2%. Clinical outcome was assessed based on mRS. One-month, three-month, and six-month follow-up was available in >90% of the patients. MR angiogram on follow-up of nine months was done in 26 patients, and none of them had restenosis.

Conclusion: Balloon angioplasty is a safe option and can be effectively used in patients of ICAD with acceptable risks and promising outcomes.

Background: There is a paucity of reliable data regarding incidence of acute spinal cord infarction in population-based studies.

Objectives: To determine the incidence of acute spinal cord infarction using a population-based design.

Methods: Medical records and neuroimaging data of all patients with acute spinal cord infarction from Stearns and Benton Counties, Minnesota, between January 1, 2010 and May 31, 2014 were reviewed. Patients with a first-time diagnosis of spinal cord infarction were categorized as primary or secondary depending upon underlying etiology identified. We calculated the incidences of primary and secondary spinal cord infarction adjusted for age and sex based on the 2010 US census (189,093 resident populations).

Results: The age- and sex-adjusted incidence of spinal cord infarction was 3.1 [95% confidence interval (CI) 1.6-7.2] per100,000 person-years. The age- and sex-adjusted incidence of primary and secondary spinal cord infarction was 1.5 [95% CI 0.6-3.6] and 1.6 [95% CI 0.6-3.6] per 100,000 person-years, respectively. The age-adjusted incidences among men and women were 1.5 [95%CI 0.6-3.7] and 4.6 [95% CI 2.2-8.7] per 100,000 person-years, respectively. No case fatality was observed at one month.

Conclusion: We provide incidence rates for acute spinal cord infarction to assist in future studies and resource allocation.

Objective: This is a case report of an adult male with complex type IV intraosseous DAVF causing severe venous hypertension and bony destruction, presenting with severe hemotympanum, and a novel way of staged arterial and venous embolizations to treat the emergent symptoms.

Methods: First and second stages were direct selective arterial embolizations using Onyx liquid agent. Goal was to reduce flow into the fistula by embolizing the feeder branch and distal penetration of the nidus with Onyx. The third stage was performed through the venous route: the transverse sinus and the sigmoid sinus were embolized using Penumbra Ruby coils and Onyx, two microcatheters were used and two large coils were placed simultaneously to form a stable coil mass, and the entire sinus was embolized using Coils and Onyx.

Results: Patient's venous hypertension and degree of hydrocephalus had significantly decreased after the procedure. He was able to return to work, but was instructed to avoid heavy lifting and placing anything in and around his right ear.

Conclusions: Multiple step arterial and venous embolization procedures were successful in decreasing the frequency of hemotympanum, degree of hydrocephalus, and improving quality of life of this patient.

Purpose: Shared decision-making, when physicians and patients collaborate and agree on health care decisions, is a key tenant of patient-centered care. Choice of access site for neurovascular procedures is rarely a shared decision point between physicians and patients. We present our initial evaluation of patient preference for radial over femoral access for cerebrovascular procedures.

Materials and methods: IRB approved single-center, prospective, and consecutive survey of all patients undergoing transradial access for cerebrovascular imaging and intervention. Primary inclusion criteria were patients who had previously undergone a transfemoral access procedure and chose to have their second procedure via a transradial approach. All patients underwent pre-procedural neurologic and extremity exams (including Barbeau tests for radial access suitability prior to radial access), post-procedural neurological evaluation and radial access assessment post-procedure, and complete neurological and radial access-site evaluation in the neurointerventional outpatient clinic 1-2 week post-procedure.

Results: Twenty five consecutive patients who underwent radial access cerebrovascular procedures after previous femoral access cerebrovascular procedures (16 diagnostic angiograms and 9 interventional procedures) were included. No major complications (including hematomas, infection, or delayed radial artery occlusion) were encountered during the immediate post-procedurral period or on outpatient follow-up (average 8 days). On immediate post-procedural examination, 16% had mild bruising and 24% had mild pain at the radial access site. Of the 25 patients included in this study, 24 strongly preferred radial access over femoral access and reported that, if they needed another procedure, they would prefer radial access.

Conclusion: There was nearly unanimous patient preference for radial over femoral access for cerebrovascular procedures in this single-center prospective analysis. There were no major complications and no incidences of delayed radial occlusion. In the current age of value-based and patient-centered medicine, the radial approach should be considered for nearly all neurovascular procedures.

Background: The management of patients with acute transient ischemic attack (TIA) or minor stroke is highly variable. Whether hospitalization of such patients significantly improves short-term clinical outcome is unknown. We assessed the short-term clinical outcome associated with inpatient versus outpatient management of patients with TIA or minor stroke.

Methods: We evaluated a consecutive series of patients with acute TIA or minor ischemic stroke (NIH Stroke Scale score ≤ 3) presenting to a single emergency department (ED). We randomized patients to either hospital-based or outpatient-based management. All patients underwent interview and examination 7-10 days following the index event.

Results: This study included 100 patients, 41 with TIA and 59 with minor stroke. Nineteen (46%) of the TIA patients and 29 (49%) of the minor stroke patients randomized to hospital management, and the remaining 22 TIA patients and 30 minor stroke patients randomized to outpatient-based management. In the patients with a minor stroke, neurologic worsening occurred in 6 out of 29 (21%) in the inpatient arm compared with 3 out of 30 (10%) in the outpatient arm (p = 0.3). In none of these cases was acute interventional therapy or need for urgent admission considered medically appropriate. In the patients with a TIA, recurrence of a TIA occurred in 2 out of 19 (11%) in the inpatient arm compared with 2 out of 22 (9%) in the outpatient arm (p = 1). None of the patients with a TIA randomized to the inpatient arm experienced a stroke compared with 1 out of 22 in the outpatient arm (p = 1). There were no deaths in either group.

Conclusion: Routine hospitalization of all patients with TIA or minor ischemic stroke may not positively affect short-term clinical outcome.

We present a rare case of bilateral expanding traumatic pseudoaneurysms of the ophthalmic arteries, due to a gunshot. The aneurysms presented with epistaxis. After a failure of conservative management, coil embolization of the aneurysms resulted in complete occlusion, with preservation of flow in the parent vessels.

Objective: To investigate the awareness and the use of Spanish version of National Institutes of Health Stroke Scale (NIHSS) throughout the United States (US) by regions using a web-based survey.

Methods: A survey targeting physicians from two specialties that regularly manage acute stroke patients was conducted from February to August of 2015. Academic centers from the Accreditation Council for Graduate Medical Education online directory belonging to emergency medicine (EM) and neurology residency programs were identified. The questionnaire was composed of ten questions separated into three different groups. The responses received from the programs were separated by specialty and grouped into different regions in the US for comparison.

Results: Out of 230 residency-invited programs, we received a total of 73 responses, 35 from EM and 26 responses from neurology residency programs. In addition, 12 respondents were categorized as unknown recipients. The South region had the highest response rate with 30.3%. There was no significant difference in the responses by region if Puerto Rico was not analyzed. Interviewees reported a substantial percentage of Spanish-speaking patients reported across the regions and more than 75% of the programs report lack of knowledge of the Spanish version of the NIHSS and/or the use of it.

Conclusion: There may be a need to increase awareness and to promote the use of the Spanish version of the NIHSS. Spanish-speaking population in the US may be inaccurately assessed for acute stroke and could impact the outcomes. Larger population studies should be conducted to confirm our findings.

Author contributions: Dr. Villalobos and Dr. Barnes are involved in formulating the study concept and design; Dr. Rodriguez and Dr. Maud are involved in manuscript writing; Dr. Qureshi is involved in statistical analysis of the data; Dr. Cruz-Flores is involved in critical revision of the manuscript.

Disclosures: Dr. Villalobos reports no disclosure; Dr. Barnes reports no disclosure; Dr. Qureshi reports no disclosure; Dr. Cruz-Flores reports no disclosure; Dr. Maud reports no disclosure; Dr. Rodriguez reports no disclosure.

Background: Mycotic aneurysms are a complication of infective endocarditis. Infection of left ventricular assist devices (LVADs) may lead to bacteremia and fever causing complications similar to those seen in patients with prosthetic valve endocarditis. Intracranial mycotic aneurysms are rare, and their presence is signaled by the development of subarachnoid hemorrhage in the setting of bacteremia and aneurysms located distal to the circle of Willis.

Case presentation: We present the case of a patient with a LVAD presenting with headache who is found to have an intracranial mycotic aneurysm through computed tomography angiography of the head. The patient was successfully treated with endovascular intervention.

Conclusion: In patients with LVADs, mycotic aneurysms have been reported, however not intracranially. To the best of our knowledge, this is the first intracranial mycotic aneurysm secondary to LVAD infection that was successfully treated with endovascular repair. Intracranial mycotic aneurysms associated with LVADs are a rare phenomenon. The diagnosis of mycotic aneurysms requires a high index of suspicion in patients who present with bacteremia with or without headache and other neurological symptoms.

Disclosure: None.

Introduction: The purpose of this study was to evaluate safety and efficacy of intensified antiplatelet therapy guided by VerifyNow assay P2Y₁₂ reaction unit (PRU) reported values in patients undergoing neuroendovascular procedures.

Methods: An observational, retrospective review was conducted at a single academic tertiary referral center and comprehensive stroke center from December 1, 2012, to August 31, 2014. The primary objective was to determine the prevalence of thromboembolic complications stratified by preprocedural PRU values. Secondary outcomes were assessed by investigating whether the goal PRU value of 190 or less is sufficient to reduce thromboembolic complications on the day of the procedure, and 30- and 90-day postprocedure.

Results: There was no statistically significant difference in the overall rate of complications in the two groups (two events in the group with preprocedural PRU values of 190 or more versus seven events in the group with preprocedural PRU values of less than 190, p = 0.668). Furthermore, the rates of thromboembolic events by 90 days were not significantly different in the two groups (one event in the group with preprocedural PRU ≥ 190 versus four events in patients with preprocedural PRU < 190, p = 1). Similarly, there was no statistically significant difference in the rate of hemorrhagic events in the two groups by 90-day postprocedure (one versus three events, p = 0.558).

Conclusion: The observed rate of thromboembolic and hemorrhagic complications in patients with preprocedural PRU values of less than 190 was not significantly different from the rate observed in patients with preprocedural PRU values of greater than 190. Sources of funding: No external funding used.