Alan O'Hare

Retrieval of a Migrated Coil Using an X6 MERCI Device

Coil migration is a recognised but rare complication of endovascular coiling. Many techniques are available commercially for coil retrieval. We report the case of an acute subarachnoid hemorrhage in a 54-year-old woman in which a migrated coil was successfully retrieved using an X6 MERCI device.

Value of CT angiography in anterior circulation large vessel occlusive stroke: Imaging findings, pearls, and pitfalls

Hyperacute stroke imaging is playing an increasingly important role in determining management decisions in acute stroke patients, particularly patients with large vessel occlusive stroke who may benefit from endovascular intervention. CT angiography (CTA) is an important tool in the work-up of the acute stroke patient. It reliably detects large occlusive thrombi in proximal cerebral arteries and is a quick and highly accurate method in identifying candidates for endovascular stroke treatment. In this article we review the imaging findings on CTA in acute large vessel occlusive stroke using a pictorial case based approach. We retrospectively reviewed CTA studies in 48 patients presenting with acute anterior circulation large vessel occlusive stroke who were brought for intra-arterial acute stroke intervention. We discuss and illustrate patterns of proximal intracranial arterial occlusion, collateralization to the occluded territory, as well as reviewing some important pearls, pitfalls and teaching points in CTA assessment of the acute stroke patient. Performed from the level of the aortic arch CTA also gives valuable information regarding the state of other vessels in the acute stroke patient, identifying additional significant vascular stenoses or occlusions, and as we illustrate, can demonstrate other clinically significant findings which may impact on patient management and outcome.

Coil Migration through a Neuroform 3 Stent during Endovascular Coiling: A Case Report

A 43-year-old woman attended for stent assisted coiling. A Neuroform 30 × 4.5 mm stent had been successfully placed over the left periophthalmic aneurysm. During the coiling the first coil migrated through the crowns in the stent, lodging at the MCA bifurcation. We believe that the coil herniated through the overlying stent due to the carotid siphon curvature and the open cell design. Furthermore the distal markers of the stent impeded coil extraction with a MERCI device.

Outcome Prediction in Acute Stroke Patients Considered for Endovascular Treatment: a Novel Tool

Functional outcome following emergent intra-arterial thrombectomy is variable and likely reflects the heterogeneous characteristics of acute stroke patients. The aims of our study were (1) to study which pre-treatment variables correlate with functional outcome and (2) to devise a tool which would reliably predict outcome. Prospective data of patients treated with intra-arterial mechanical thrombectomy in our institution between 2010 and 2012 were collected. A preliminary univariate analysis of baseline variables was performed and data outliers were identified by constructing scatter and box plots. Systematic bivariate analysis was then carried out using a linear regression model and the individual contributing weights of the variables to outcome calculated. The B and constant values from the regression were used to construct a predictive formula. Fifty-seven patients, 35 males (61.4%) and 22 females (38.6%) with a mean age of 62.3 years (range 26–87) were included in the cohort. Statistical correlations of baseline variables and functional outcome showed that age, National Institutes of Health Stroke Scale at presentation and CT leptomeningeal collaterals were strongly correlated (p<0.01), and were later included in the linear regression model. A tool was devised from the regression formula combining weighted inputs of the three variables. Regression statistics and residual analysis were then performed to assess the accuracy and reliability of the proposed tool. The proposed tool is easy to use and reliably predicts functional outcome prior to endovascular therapy. It may help clinical decision-making in the acute setting and offers ‘tailor-made’ outcome expectations.

Endovascular treatment for acute ischaemic stroke with large vessel occlusion: the experience of a regional stroke service.

AIM To report the experience of a regional stroke referral service with endovascular treatment for patients with acute ischaemic stroke (AIS) and large vessel occlusion. MATERIALS AND METHODS A prospective review was undertaken of 93 consecutive cases receiving endovascular treatment for AIS over a 42-month period (January 2010 to June 2013). The National Institutes of Health Stroke Scale (NIHSS), location of large vessel occlusion, details of endovascular procedure, and degree of reperfusion achieved (Thrombolysis In Cerebral Infarction [TICI] score) were recorded. Mortality and functional outcome (modified Rankin Scale [mRS]) were measured at 90 days. RESULTS The mean patient age was 62 years (range 26-87 years). The mean NIHSS at presentation was 16 (range 6-29). All patients had confirmed proximal large-artery occlusion on computed tomography (CT) angiography: 87 in the anterior circulation, six in the posterior circulation. Of the 93 patients treated, 64 (69%) received intravenous thrombolysis. Successful reperfusion (TICI grade 2a to 3) was achieved in 80 (86%) cases. There were 13 (14%) cases of failed vessel recanalisation (TICI grade 0). Good functional outcome (mRS ≤2) was achieved in 51 (55%) cases. The 90-day mortality was 20 (22%) cases. Fifty-seven (61%) cases were transferred from outside centres. There was no significant increase in morbidity or mortality for transferred patients. CONCLUSION Successful endovascular recanalisation can result in good functional outcomes for patients with AIS and large vessel occlusion. Our interventional neuroradiology service provides endovascular treatment as part of a regional stroke service without increase in morbidity or mortality for patients transferred from outside institutions.

Imaging of Adult Ocular and Orbital Pathology - a Pictorial Review

Orbital pathology often presents a diagnostic challenge to the reporting radiologist. The aetiology is protean, and clinical input is therefore often necessary to narrow the differential diagnosis. With this manuscript, we provide a pictorial review of adult ocular and orbital pathology.

Teaching NeuroImages: Ectopic posterior pituitary

Ectopic posterior pituitary results from incomplete caudal extension of the diencephalon during embryogenesis.1 The portal circulation carrying hypothalamic-releasing hormones to the adenohypophysis is disrupted, resulting in growth hormone deficiency and more rarely panhypopituitarism.

Hurler syndrome (Mucopolysaccharidosis type I).

Hurler syndrome is a rare lysosomal storage disorder with a prevalence of 1 in 100 000. It is caused by a defective IDUA gene which codes for α-L iduronidase and has an autosomal recessive inheritance. Enzyme deficiency results in accumulation of dermatan and heparan sulfate in multiple tissues which leads to progressive deterioration and eventual death. The condition manifests with profound intellectual disability, corneal clouding, cardiac disease and characteristic musculoskeletal manifestations. …

20 YEAR OLD LADY WITH A PARASPINAL MASS

A 20 year old female presented with a 4 month history of right upper limb pain and paraesthesias. She had no systemic symptoms and no prior medical or family history of note. MRI revealed a right-sided intradural extramedullary mass extending from C7-T1 and displacing the spinal cord. While awaiting surgery her symptoms progressed to involve the right lower limb. She was re-imaged and the lesion now extended from C5 to T3 with spinal cord compression at C7-T1. The radiological features and recent rapid growth were felt to be in keeping with a large plexiform neurofibroma. The patient underwent emergency resection of the lesion and pathology revealed Hodgkins Lymphoma (HL)-mixed cellularity type. A mediastinal mass was identified on further imaging and biopsy confirmed the diagnosis of HL-stage IV. The patient is currently undergoing treatment with ABVD chemotherapy. CNS-HL is extremely rare and may occur de novo or in association with systemic disease. Lesions may be parenchymal or dural based and are usually intracranial with an increased risk of CNS involvement in HL-mixed-cellularity type as in our patient. This is the first report in the literature of CNS-HL radiologically mimicking a paraspinal plexiform neurofibroma.

Neuroimaging of chronic alcohol misuse.

Alcohol is one of the most commonly abused substances worldwide. It results in a wide range of diseases and disorders affecting many organ systems. Alcohol‐related nutritional deficiencies and electrolyte disturbance leave chronic abusers at risk of a range of demyelinating conditions to which the radiologist and clinician should always be alert. These include Wernickes encephalopathy, Korsakoffs syndrome, Marchiafava‐Bignami disease and osmotic demyelination. Cerebral volume loss is also a commonly encountered neuroimaging phenomenon in chronic alcohol abusers. Neuroimaging with CT and MR, with a focus on FLAIR and diffusion‐weighted MR sequences, play an important role in the diagnosis and often monitoring of these conditions. We present an educational review of these entities in terms of their clinical features, neuropathology and imaging features along with a case example of each condition.