Alejandro Enriquez-Marulanda

Validation of a Predictive Scoring System for Ventriculoperitoneal Shunt Insertion After Aneurysmal Subarachnoid Hemorrhage

BACKGROUNDnHydrocephalus is a frequently encountered complication in the context of aneurysmal subarachnoid hemorrhage (aSAH). Here, we performed an external validation of the recently proposed postsubarachnoid shunt scoring (PS3) system, which aims to stratify patients presenting with aSAH based on their relative risk of requiring ventriculoperitoneal (VP) shunt insertion.nnnMETHODSnA retrospective review of all patients presenting with aSAH to our institution between July 2007 and December 2016, who underwent computed tomography imaging at the time of hospital admission, was performed.nnnRESULTSnA total of 242 patients (66.1% women) with aSAH were included in the analysis with a mean age of 55.6 years. Sixty-four (26.4%) patients had a Hunt and Hess grade of 4 or 5 on admission. An external ventricular drain (EVD) was placed in 130 (53.7%) patients during the hospital admission. EVD placement was found to correlate with an increased rate of VP shunt placement (P < 0.001), and a trend toward an association between a high Hunt and Hess grade and VP shunt placement was observed (Pxa0= 0.05). The area under the receiver operating characteristic curve for the PS3 system was found to be 0.845. The system reliably predicted shunt-dependent chronic hydrocephalus in our patient cohort (odds ratio, 3.36; 95% confidence interval, 2.31-4.89; P < 0.001).nnnCONCLUSIONSnData from this study validated the previously proposed PS3 system, which was found to more accurately predict shunt-dependent chronic hydrocephalus in patients with aSAH compared with other such systems in the neurosurgical literature, such as the chronic hydrocephalus ensuing from SAH score, Barrow Neurological Institute, and shunt dependency in aSAH systems.

Combined Outcomes of Endovascular or Surgical Treatment of Unruptured Anterior Communicating Artery Aneurysms: Is a More Aggressive Management Strategy Warranted?

BACKGROUNDnUpdated natural history studies that suggest anterior communicating artery aneurysms have a higher risk of rupture than formerly appreciated. As endovascular and open techniques advance, morbidity may fall to levels that suggest the feasibility of intervention even for small aneurysms. This study was conducted to assess the risk associated with treating smaller, unruptured anterior communicating artery aneurysms.nnnMETHODSnA cross-sectional study of 149 patients with unruptured anterior communicating aneurysms treated over a 6-year period was performed. Treatment was based on an estimate of the highest efficacy/lowest risk for each patient. Outcomes were recorded at 3 months and 1 year after treatment. The primary outcome measure was a modified Rankin scale score of >2 at 1 year, or persistent cognitive impairment confirmed by a neurologist.nnnRESULTSnThe average patient age was 61 years (range, 34-84 years), and the median aneurysm size was 5.5 mm (interquartile range, 4-7 mm). Clipping was performed in 98 patients (65.8%). Poor outcome was observed in 12 patients (8%). Neither aneurysm size nor treatment method was predictive of poor outcome. Both a history of coronary artery disease/myocardial infarction and age were most significantly associated with poor outcome (coronary artery disease/myocardial infarction: odds ratio [OR], 8.11; 95% confidence interval [CI], 2.20-29.86; Pxa0= 0.002; age: OR, 1.09; 95% CI, 1.019-1.17; Pxa0= 0.013). Dichotomized for age >65 years, the odds of poor outcome increased nearly 11-fold (OR, 10.93; 95% CI, 2.29-52.03; Pxa0= 0.003).nnnCONCLUSIONSnThe risk associated with treating unruptured anterior communicating artery aneurysms in patients age <65 years is low. Comparing risk with natural history studies, these patients can be expected to outperform natural history within 5 years. Recognizing the risk of smaller anterior communicating artery aneurysms, these findings suggest that treatment of even small lesions may be beneficial.

Transarterial Onyx Embolization of Bilateral Transverse–Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist—Initial U.S. Experience with Copernic RC Venous Remodeling Balloon

BACKGROUNDnCurrently, the mainstay treatment of dural arteriovenous fistula (DAVF) involves endovascular approaches, especially for high-grade lesions. Transarterial embolization with preservation of venous sinuses has become the preferred approach due to the development of newer liquid embolic agents. For further precision during embolization, the use of temporary balloon occlusion to protect the patency of dural sinuses from the embolic agents migration has been described.nnnMETHODSnA 64-year-old man presented with bilateral pulsatile tinnitus and visual decline. A diagnostic cerebral angiogram demonstrated a complex bilateral Borden type II and Cognard type IIB DAVF. Treatment was carried out endovascularly under general anesthesia in a staged fashion. In the first stage, the balloon was inflated during embolization to protect the right transverse sigmoid venous sinus system and torcula. In the second stage, the balloon was again inflated to protect the left transverse sigmoid venous sinus system and torcula during embolization. Complete obliteration of the left DAVF was achieved, and patency of the left transverse and sigmoid sinuses was preserved. Patency of the right transverse and sigmoid sinus was also conserved post procedure.nnnRESULTSnThe patient was treated successfully with transarterial Onyx embolization with transvenous balloon protection of the sinus.nnnCONCLUSIONSnThis case is the first reported use of the Copernic RC balloon in the United States under the compassionate use guidelines of the U.S. Food and Drug Administration. The use of this balloon is becoming a useful treatment alternative in selected cases of DAVFs as it improves the safety and efficacy of transarterial embolization as evidenced in this case.

Cerebral toxoplasmosis in an MS patient receiving Fingolimod

Multiple Sclerosis (MS) is an autoimmune disease in which lymphocytes target putative myelin antigens in the CNS, causing inflammation and neurodegeneration. Fingolimod (FTY720) is an immunosuppressive drug used as a second line therapy for relapsing forms of MS due to its safety profile and good response to treatment. Despite its safety, there are still concerns about the possibility of Fingolimod being linked to the development of opportunistic infections like disseminated varicella zoster infections and herpes simplex encephalitis. In this case report, we describe one patient with past medical history of MS in current treatment with Fingolimod for the last year which presents herself with hemiparesis, fever and fatigue. The initial MRI showed multiple demyelinating-like lesions that could have corresponded to the tumefactive form of MS relapse. The blood work up revealed leukopenia with lymphopenia and a CD4+ count of 200 cell/mm3. Treatment for acute relapse was initiated with little to no response. Further examination was carried by the clinicians, a lumbar puncture was performed and it showed pleocytosis with increased protein levels. Later, several serologic studies were performed and both IgM and IgG antibodies for Toxoplasma were positive. Diagnosis of cerebral toxoplasmosis was made and there was no evidence of HIV infection or other causes of secondary immunodeficiency in this patient, except the use of fingolimod. Evidence of decreased levels of CD4+ due to Fingolimod use is concerning. The risk of opportunistic infections in these patients must be considered in order to start or continue therapy with these agents. Further studies are needed to determine the percentage of the population at risk of immunosuppression and its long-term consequences as well as new actions to prevent infections.

Extra luminal migration of ingested fish bone to the spleen as an unusual cause of splenic rupture: Case report and literature review

Highlights • Foreign body ingestion is a relatively common and benign condition; some serious complications, however, can arise.• Approximately 1% of all ingested FB will cause perforation requiring surgical treatment.• Sharp FB, such as fish bones, chicken bones and needles, are more prone to migrate outside the gastrointestinal lumen if they are not removed early.• The patient reported here is the first one in the literature to present a splenic rupture due to extra-luminal migration of an ingested fish bone through the splenic flexure of the colon.

Use of Flow Diversion for the Treatment of Distal Circulation Aneurysms: A Multicohort Study

OBJECTIVEnThe safety and efficacy of flow diversion for distal circulation aneurysms of the cerebral vasculature has not been well evaluated. The objective of this study was to assess the use of flow diversion for distal circulation aneurysms (defined as at or beyond the M1, P1, and A1 segments of the middle cerebral artery, posterior cerebral artery, and anterior cerebral artery, respectively) in an international multicenter cohort.nnnMETHODSnClinical and radiologic records from all patients undergoing flow diversion treatment of distal circulation aneurysms at 3 academic centers (2 in the USA and 1 in Europe) from 2014 until 2017 were retrospectively reviewed.nnnRESULTSnForty-six patients (mean age, 58.2 years; 33 women) harboring 46 aneurysms who underwent treatment with either the Pipeline Embolization Device (Medtronic Inc., Dublin, Ireland) or the Flow Re-Direction Endoluminal Device (MicroVention, Tustin, California, USA) were included in these analyses. Thirty-four aneurysms (74%) were located in the anterior circulation and 12 (26%) were located in the posterior circulation. With a mean follow-up of 13.0 months, complete (100%) and near-complete (90%-99%) occlusion was noted in 36 aneurysms (78.2%). Angiographic evidence of side branch or perforator vessel coverage was present in 35 aneurysms (76.1%) but was not associated with failure to occlude at follow-up (Pxa0= 0.06). All patients had good functional outcomes after treatment (modified Rankin Scale score 0-2). There were 2 cases (4.3%) of perforator vessel stroke and no hemorrhagic complications.nnnCONCLUSIONSnFlow diversion for aneurysms beyond the circle of Willis has occlusion rates comparable to alternative treatments and low morbidity. The clinical significance of flow limitation through covered side branches requires further investigation.

Quantitative Assessment of In-Stent Stenosis After Pipeline Embolization Device Treatment of Intracranial Aneurysms: A Single-Institution Series and Systematic Review

BACKGROUNDnVery little is known about the incidence of in-stent stenosis after flow diverter treatment of intracranial aneurysms. We sought to evaluate the incidence and clinical significance of in-stent stenosis at angiographic follow-up after Pipeline embolization device (PED) placement using quantitative measures.nnnMETHODSnThe clinical and radiological records from all patients undergoing PED treatment of intracranial aneurysms at a major U.S. academic center from March 2013 to July 2017 were retrospectively reviewed. A modified version of the North American Symptomatic Carotid Endarterectomy criteria was used to quantify the degree of stenosis on the most recent postprocedural angiogram. The percentage of stenosis was calculated as 1xa0- (narrowest vessel diameter/maximal midstent diameter within the artery) at the first follow-up angiogram. The PubMed, Web of Science, and EMBASE databases were additionally searched from inception until April 2018 for the rates of in-stent stenosis after flow diversion.nnnRESULTSnA total of 155 patients (mean age, 58.3 years; 30 males) with 162 aneurysms underwent treatment with the PED at our institution. In-stent stenosis was detected in 12 patients (7.1%) at 6 months. The mean percentage of stenosis was 39.7%. All 12 patients remained asymptomatic, except for 1 who developed hemiplegia secondary to an unrelated ischemic stroke. The aneurysm occlusion rates at 6 months were comparable between the stenosis and nonstenosis cohorts (76.9% and 71.6%, respectively). Within the stenosis cohort, further follow-up angiograms after 6 months were available for 6 patients, of whom 3 (50%) had either complete resolution or improvement. Of the 43 included studies, 28 reported on the use of the PED, with 2448 patients. The mean reported rate of in-stent stenosis after PED placement was 8.8% (range, 0%-39%).nnnCONCLUSIONSnIn-stent stenosis remains a rare complication of PED placement for intracranial aneurysms. When occurring, it appears to largely be self-limiting, with a benign clinical course.

Statin Therapy and Diabetes Do Not Affect Aneurysm Occlusion or Clinical Outcomes Following Pipeline Embolization Device Treatment: a Preliminary Study

BACKGROUNDnThe effect of statins and diabetes on angiographic and clinical outcomes in aneurysms treated with pipelines has not been adequately reported. Our aim is to assess the effect of concurrent statin medications and diabetes mellitus (DM) on aneurysm occlusion status and outcomes in patients treated with the pipeline embolization device.nnnMETHODSnA retrospective review of our institutions database of aneurysms treated with the pipeline embolization device between 2013 and 2017 was conducted. We collected data about statin therapy status and intensity, and identified patients with a documented history of DM. Our primary outcome was aneurysm obliteration seen on digital subtracted angiography or magnetic resonance angiography at last follow-up.nnnRESULTSnWe identified 151 patients with 182 aneurysms for this cohort, with a median radiographic follow-up time of 7.2 months (6.1-14.5). Thirty-nine patients were taking statins, and 112 patients did not receive statins. Log-rank tests revealed no statistically significant difference in occlusion rates between patients with and without statin therapy (Pxa0= 0.30). A history of DM was documented in 11 patients, with 14 aneurysms in total; 140 patients with 168 aneurysms had no history of DM. Similarly, there were no differences in occlusion rates between the diabetic and nondiabetic groups in multivariate analysis (Pxa0=xa00.24). Only 2 patients showed significant in-stent stenosis on angiographic follow up, and both were diabetic.nnnCONCLUSIONSnOur analysis did not identify a statistically significant association between statin therapy or DM and higher occlusion rates or better outcomes after pipeline embolization. Diabetic patients may have a theoretic risk of significant in-stent stenosis.

Deep Brain Stimulation Surgery for Status Dystonicus: A Single-Center Experience and Literature Review

BACKGROUNDnStatus dystonicus (SD) is a life-threatening complication in which episodes of dystonic movements become increasingly frequent and severe, requiring urgent hospital admission, and can lead to respiratory, metabolic, and bulbar complications. Pharmacologic treatment has been the mainstay management for this complication; however, many refractory patients will still require further treatment. Deep brain stimulation (DBS) is an established therapeutic strategy that has been used for dystonia, and now it has been proposed to be used for SD.nnnMETHODSnIn this case series, we describe our experience with early DBS placement in 5 patients with SD to control symptoms that are refractory to pharmacologic therapy. In addition, we present a literature review of this therapy in the treatment of SD.nnnRESULTSnBefore discharge, symptomatic relief (decrease of dystonic movements and resolution of abnormal postures) was evidenced in all patients with a median of 3 days (interquartile range, 1-7) after surgery was performed. A follow-up Unified Dystonia Rating Scale score and Burke-Fahn-Marsden rating scale motor subscale score, at 6 months after hospital discharge with values being inferior to 20 and 30, respectively, for all cases. None of the patients had a recurrence of SD in the last follow-up period.nnnCONCLUSIONSnDBS surgery is a suitable, versatile, reversible and adequate therapy in the treatment of SD that is refractory to initial pharmacologic treatment.

Proposal of a Grading System for Predicting Discharge Mortality and Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage

BACKGROUNDnSeveral outcome prediction systems have been developed to evaluate aneurysmal subarachnoid hemorrhage (aSAH). However, they can be difficult to use and can contain subjective elements. We sought to identify the predictors of aSAH outcomes at discharge to provide an accurate and reliable scoring system.nnnMETHODSnA retrospective cohort study of patients with aSAH at an academic institution from 2007 to 2016 was conducted. The primary outcome measure was the modified Rankin scale (mRS) score at discharge, with mRS scores of 0-2 considered favorable and mRS scores of 3-6 considered unfavorable. Factors significant on multivariate regression were used to develop a scale, which was compared with other established grading systems using receiver operating characteristic curves.nnnRESULTSnWe identified 279 patients with aSAH, 37.3% of whom had unfavorable outcomes. The proposed scale assigns 2 points for postresuscitation Glasgow coma scale score of ≤8, 1 point for age ≥70 years, 1 for antiplatelet therapy on admission, and 1 for SAH thickness of ≥10 mm, with a total score of 0-5. The proposed, Subarachnoid Hemorrhage International Trialists, and Hunt and Hess scales had similar areas under the curve (85.2%, 84.8%, and 80.6%, respectively; P > 0.05) but were significantly better than the World Federation of Neurological Surgeons (78.5%; Pxa0= 0.001) and modified Fisher (60.8%; P < 0.001) scales.nnnCONCLUSIONnWe propose a grading scale to predict discharge mortality and functional outcomes in patients with aSAH. The proposed scale outperformed most other outcome prediction scales. The proposed scale contains objective elements, is easy to apply by memory, and can be a useful and effective measure to predict aSAH outcomes.