Anthony M. Burrows

Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review

Background and purpose Studying the imaging and histopathologic characteristics of thrombi in ischemic stroke could provide insights into stroke etiology and ideal treatment strategies. We conducted a systematic review of imaging and histologic characteristics of thrombi in acute ischemic stroke. Materials and methods We identified all studies published between January 2005 and December 2015 that reported findings related to histologic and/or imaging characteristics of thrombi in acute ischemic stroke secondary to large vessel occlusion. The five outcomes examined in this study were (1) association between histologic composition of thrombi and stroke etiology; (2) association between histologic composition of thrombi and angiographic outcomes; (3) association between thrombi imaging and histologic characteristics; (4) association between thrombi imaging characteristics and angiographic outcomes; and (5) association between imaging characteristics of thrombi and stroke etiology. A meta-analysis was performed using a random effects model. Results There was no significant difference in the proportion of red blood cell (RBC)-rich thrombi between cardioembolic and large artery atherosclerosis etiologies (OR 1.62, 95% CI 0.1 to 28.0, p=0.63). Patients with a hyperdense artery sign had a higher odds of having RBC-rich thrombi than those without a hyperdense artery sign (OR 9.0, 95% CI 2.6 to 31.2, p<0.01). Patients with a good angiographic outcome had a mean thrombus Hounsfield unit (HU) of 55.1±3.1 compared with a mean HU of 48.4±1.9 for patients with a poor angiographic outcome (mean standard difference 6.5, 95% CI 2.7 to 10.2, p<0.001). There was no association between imaging characteristics and stroke etiology (OR 1.13, 95% CI 0.32 to 4.00, p=0.85). Conclusions The hyperdense artery sign is associated with RBC-rich thrombi and improved recanalization rates. However, there was no association between the histopathological characteristics of thrombi and stroke etiology and angiographic outcomes.

Treatment of a pediatric recurrent fusiform middle cerebral artery (MCA) aneurysm with a flow diverter

Pediatric patients with aneurysm often have different localizations and morphologies from adults and recurrences are not uncommon after successful clip reconstruction/obliteration. Treatment of a recurrent pediatric aneurysm after clip ligation is a technical challenge. We present the case of an adolescent with a middle cerebral artery (MCA) fusiform aneurysm which recurred following clip reconstruction and bypass. The aneurysm was successfully treated with endovascular flow diversion.

Periprocedural and mid-term technical and clinical events after flow diversion for intracranial aneurysms

Object Flow diversion has emerged as a promising treatment alternative for cerebral aneurysms. As a new device, treatment-related events and complications are currently being characterized. Methods Data on 100 consecutive procedures with the intention to use flow diversion were prospectively collected and analyzed retrospectively. Results Ninety-five aneurysms were treated in 93 patients during 100 consecutive procedures in which the intention was to treat an intracranial aneurysm with flow diversion. Death occurred in 1% and permanent morbidity in 1%. However, periprocedural technical complications occurred in 35% of the procedures and included proximal device migration in 12%, incomplete device expansion in 9%, catheter-induced vasospasm in 6%, and artery perforation from the wire in 3%. Perioperative clinical events were seen in 28% (thromboembolism and access site complications were the most common, being observed in 6.5% of patients). Worsened extraocular motility was seen in 5.4% and resolved in 4/5 patients. Mean clinical follow-up was 17 months. There were no late clinical or technical issues resulting in permanent deficits, although one patient suffered worsening ataxia. Overall, using very strict angiographic criteria, complete angiographic obliteration was 50% at 6 months and 69% after 1 year. Conclusions Flow diversion for intracranial aneurysms is a safe and effective treatment. Technical and clinical events are common in the perioperative period. Careful perioperative care and proper management of technical and clinical events encountered is key to achieving low morbidity and mortality. Late clinical events can occur but are unlikely to result in permanent complications.

Flow Diversion for Ophthalmic Artery Aneurysms

This is a retrospective review of 48 patients with 50 carotid-ophthalmic aneurysms in which 44 patients with 46 aneurysms were treated with flow diversion from June 2009 to June 2015. There were no permanent adverse visual outcomes. There was 1 death due to late intraparenchymal hemorrhage (2.2%). Six-month angiography showed complete occlusion in 24 of 37 patients (64.9%), and 3-year angiography results showed occlusion in 24 of 25 patients (96%). SUMMARY: Endovascular treatments of ophthalmic segment aneurysms are commonly used but visual outcomes remain a concern. We performed a retrospective review of patients with carotid-ophthalmic aneurysms treated with flow diversion from June 2009 to June 2015. The following outcomes were studied through chart review: visual outcomes, complications, postoperative stroke and intraparenchymal hemorrhage, and clinical outcomes. Angiographic outcomes were studied with angiography and MRA at 6 months, 1 year, and 3 years. We evaluated 50 carotid-ophthalmic aneurysms in 48 patients, among whom 44 patients with 46 aneurysms underwent treatment. The mean clinical follow-up was 29 ± 22 months (range, 0–65 months). There were no permanent adverse visual outcomes. There was 1 death because of late intraparenchymal hemorrhage (2.2%). Six-month angiography showed complete occlusion in 24 of 37 patients (64.9%), and 3-year angiography results showed occlusion in 24 of 25 patients (96%). In conclusion, flow diversion is a safe and effective treatment for carotid-ophthalmic aneurysms in carefully selected patients. The risk of adverse visual outcomes is low, and most aneurysms progress to complete occlusion.

Magnetic resonance imaging–guided laser interstitial thermal therapy for previously treated hypothalamic hamartomas

OBJECTIVE Hypothalamic hamartomas (HHs) are associated with gelastic seizures and the development of medically refractory epilepsy. Magnetic resonance imaging-guided laser interstitial thermal therapy (MRg-LITT) is a minimally invasive ablative treatment that may have applicability for these deep-seated lesions. Here, the authors describe 3 patients with refractory HHs who they treated with MRg-LITT. METHODS An institutional review board-approved prospective database of patients undergoing Visualase MRg-LITT was retrospectively reviewed. Demographic and historical medical data, including seizure and medication histories, previous surgeries, procedural details, and surgical complications, along with radiological interpretation of the HHs, were recorded. The primary outcome was seizure freedom, and secondary outcomes included medication reduction, seizure frequency, operative morbidity, and clinical outcome at the latest follow-up. RESULTS All 3 patients in the multi-institutional database had developed gelastic seizures related to HH at the ages of 7, 7, and 9 years. They presented for further treatment at 25, 28, and 48 years of age, after previous treatments with stereotactic radiosurgery in all cases and partial hamartoma resection in one case. One ablation was complicated by a small tract hemorrhage, which was stable on postoperative imaging. One patient developed hyponatremia and experienced weight gain, which were respectively managed with fluid restriction and counseling. At the most recent follow-up at a mean of 21 months (range 1-32 months), one patient was seizure free while another had meaningful seizure reduction. Medication was reduced in one case. CONCLUSIONS Adults with gelastic seizures despite previous treatments can undergo MRg-LITT with reasonable safety and efficacy. This novel therapy may provide a minimally invasive alternative for primary and recurrent HH as the technique is refined.

Safety and efficacy of endovascular treatment for intracranial infectious aneurysms: A systematic review and meta-analysis

INTRODUCTION Intracranial infectious aneurysms (IIAs), or mycotic aneurysms are rare, representing between 0.7% and 5.4% of all intracranial aneurysms. To clarify the safety and efficacy of endovascular treatment of IIAs, we conducted a systematic review of the literature analyzing periprocedural and long-term clinical and angiographic outcomes. METHODS A comprehensive review of the literature for studies with ≥3 patients related to endovascular treatment of IIAs published through September 2015 was performed. Random-effects meta-analysis was used to pool the following outcomes: complete occlusion, technical success, aneurysm recurrence, rebleeding, perioperative mortality, iatrogenic rupture, perioperative stroke, procedure-related morbidity and mortality, long-term neurological morbidity and mortality, and overall good neurological outcome. RESULTS We included 11 non-comparative studies with 86 target IIAs. Complete occlusion rates were 95.3% (95% CI=91.2-99.4%). Recurrence occurred in 7.9% (95% CI=2.7-13.0%). Rebleeding occurred in 5.8% (95% CI=1.4-10.3%) of patients. Procedure-related morbidity was 12.6% (95% CI=6.1-19.2%) and procedure-related mortality was 6.1% (95% CI=1.5-10.8%). Long-term good neurological outcome was 68.0% (95% CI=55.1-80.9%). CONCLUSION Our meta-analysis demonstrated that endovascular treatment is technically feasible and effective with high rates of IIA occlusion. Despite the comorbidities of patients, endovascular approach was associated with acceptable rates of procedure-related morbidity and satisfactory rates of overall good neurological outcome.

Are routine intensive care admissions needed after endovascular treatment of unruptured aneurysms

In this series of 200 patients treated for unruptured intracranial aneurysms, 65% were sent to a routine floor instead of the intensive care unit as is commonly done. Only one patient required transfer to the ICU and thus the authors concluded that in patients without significant co-morbidities, intraoperative complications, or complex aneurysms, routine placement in the ICU after embolization is not warranted. SUMMARY: Routine intensive care unit monitoring is common after elective embolization of unruptured intracranial aneurysms. In this series of 200 consecutive endovascular procedures for unruptured intracranial aneurysms, 65% of patients were triaged to routine (non-intensive care unit) floor care based on intraoperative findings, aneurysm morphology, and absence of major co-morbidities. Only 1 patient (0.5%) required subsequent transfer to the intensive care unit for management of a perioperative complication. The authors conclude that patients without major co-morbidities, intraoperative complications, or complex aneurysm morphology can be safely observed in a regular ward rather than being admitted to the intensive care unit.

Pediatric ischemic stroke from an apoplectic prolactinoma

IntroductionPediatric pituitary neoplasms and associated pituitary apoplexy are uncommon. There are few reports in pediatric patients of pituitary apoplexy causing focal arterial compression or diffuse vasospasm resulting in cerebral infarction, and the acute, focal neurological deficits associated with stroke differ from the typical presentation of an apoplectic pituitary tumor. We report the first case of a teenage female with an apoplectic macroprolactinoma presenting with stuttering cerebral infarction secondary to compression of the internal carotid artery (ICA).CaseA 14-year-old female was transferred from an outside facility after presenting with right hand paresthesias and word-finding difficulty that eventually progressed to include right upper extremity weakness and mental status changes. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed an apoplectic macroprolactinemia and diffusion-weighted imaging showed acute stroke in the left anterior and middle cerebral artery distributions. Evaluation of the cerebral vasculature with MRA showed focal compression of the left supraclinoid ICA. Despite prompt surgical decompression, the patient developed right lower extremity weakness in addition to her other deficits though her deficits improved after inpatient rehabilitation.ConclusionsIn the pediatric population, there is only one other case of pituitary apoplexy presenting with stroke, which was secondary to vasospasm. We present the first case of pituitary apoplexy presenting with stroke secondary to ICA compression. Though rare, it is important to consider that pituitary apoplexy may present with non-classical symptoms such as ischemic stroke even in pediatric patients.

Intraneural fibroma of the median nerve at the wrist.

Distal median neuropathy from carpal tunnel syndrome is the most well known lesion affecting the median nerve. Mass lesions may affect the nerve at the wrist. We present to our knowledge the first histologically confirmed case of an intraneural fibroma.

Advances in Stroke: Vascular Neurosurgery

The indications for microsurgery in cerebrovascular pathology have been placed under increased scrutiny, given the continuous refinement of endovascular techniques. Several recent randomized studies and subgroup analyses of concluded studies have been particularly illuminating in this sense and will be the primary focus of this brief review. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) has shown that the risk of perioperative stroke is slightly higher after carotid artery stenting (CAS) than after carotid endarterectomy (CEA), whereas the reverse is true for the risk of periprocedural myocardial infarction.1 Over the past year, the CREST investigators have also reported the results of some prespecified and some ad hoc subgroup analyses. Earlier trials of CAS versus CEA had suggested higher risk of restenosis after endovascular treatment of carotid stenosis compared with CEA. However, in CREST after 2 years, the incidence of restenosis >70% or occlusion was similar in the CAS (6%) and the CEA (6.3%) groups, suggesting that restenosis may not be a major concern if endovascular treatment is contemplated.2 Female sex, diabetes mellitus, and dyslipidemia were associated with higher risk of restenosis in both groups.2 Smoking increased the risk of restenosis in patients undergoing CEA but not after stenting.2 Subgroup analysis by age confirmed that increasing age is associated with a higher risk of periprocedural stroke after CAS but did not affect …