Daniela Iancu

Computed tomography angiography intraluminal filling defect is predictive of internal carotid artery free-floating thrombus

IntroductionFilling defects at the internal carotid artery (ICA) origin in the work-up of stroke or transient ischemic attack may be an ulcerated plaque or free-floating thrombus (FFT). This may be challenging to distinguish, as they can appear morphologically similar. This is an important distinction as FFT can potentially embolize distally, and its management differs. We describe a series of patients with suspected FFT and evaluate its imaging appearance, clinical features, and evolution with therapy.MethodsBetween 2008 and 2013, we prospectively collected consecutive patients with proximal ICA filling defects in the axial plane surrounded by contrast on CT/MR angiography. We defined FFT as a filling defect that resolved on follow-up imaging. We assessed the cranial–caudal dimension of the filling defect and receiver operating characteristics to identify clinical and radiological variables that distinguished FFT from complex ulcerated plaque.ResultsIntraluminal filling defects were identified in 32 patients. Filling defects and resolved or decreased in 25 patients (78xa0%) and felt to be FFT; there was no change in 7 (22xa0%). Resolved defects and those that decreased in size extended more cranially than those that remained unchanged: 7.3xa0mm (4.2–15.9) versus 3.1xa0mm (2.7–3.7; pu2009=u20090.0038). Receiver operating characteristic analysis established a threshold of 3.8xa0mm (filling defect length), sensitivity of 88xa0%, specificity of 86xa0%, and area under the curve of 0.86 (pu2009<u20090.0001) for distinguishing FFT from plaque.ConclusionFilling defects in the proximal ICA extending cranially >3.8xa0mm were more likely to be FFT than complex ulcerated plaque. Further studies evaluating filling defect length as a predictor for FFT are warranted.

Endovascular treatment for cerebral septic embolic stroke.

This case demonstrates an alternative approach to cerebral revascularization by performing both intravascular mechanical thrombectomy and local injection of thrombolytics that may reduce mortality, bleeding, and the diminished quality of life experienced by patients following an acute septic embolic stroke.

Flow diversion in the treatment of carotid injury and carotid-cavernous fistula after transsphenoidal surgery:

We describe a case of iatrogenic carotid injury with secondary carotid-cavernous fistula (CCF) treated with a silk flow diverter stent placed within the injured internal carotid artery and coils placed within the cavernous sinus. Flow diverters may offer a simple and potentially safe vessel-sparing option in this rare complication of transsphenoidal surgery. The management options are discussed and the relevant literature is reviewed.

Quantitative non-contrast measurements improve diagnosing dural venous sinus thrombosis

IntroductionThe only direct sign of sinus thrombosis on non-contrast computerized tomography (NCCT) is the hyperdense sign. The purpose of our study was to assess quantitative parameters for diagnosis of superficial venous sinus thrombosis and to compare these quantitative criteria with the current standard of qualitative evaluation.MethodsThis retrospective case–control study included 18 patients with acute superficial sinus thrombosis and 18 matched controls. Three blinded readers independently evaluated the NCCT for the presence of hyperdense sign using axial slices only followed by axial slices with multiplanar reformats. Absolute attenuation values and ratios were calculated for thrombosed and non-thrombosed sinuses: Ratiotarget sinus/lowest attenuation sinus, Ratiotarget sinus/basilar artery, Ratiotarget sinus/internal carotid artery, Ratiotarget sinus/temporal lobe, and Ratiotarget sinus/frontal lobe.ResultsThere was a significant difference in absolute attenuation values and ratios between thrombosed and non-thrombosed sinuses, with the absolute attenuation and the Ratiotarget sinus/lowest attenuation sinus being the most differentiating. The mean attenuation for thrombosed sinuses was 69 Hounsfield units (HU) (95xa0% CI 65–72 HU) vs. 52 HU (95xa0% CI 51–54) for non-thrombosed, Pu2009<u20090.0001. The mean Ratiotarget/lowest attenuation was 1.5 (95xa0% CI 1.4–1.6) for thrombosed sinuses vs. 1.1 (95xa0% CI 1.0–1.1) for non-thrombosed, Pu2009<u20090.0001. Optimal thresholds of 62 HU and 1.3 yielded sensitivities of 81 and 84xa0%, respectively. Hyperdense sign had a sensitivity of 63xa0% on axial images and 67xa0% with the addition of multiplanar reformats.ConclusionDensity measurements result in substantial improvement over visual inspection in the diagnosis of superficial venous sinus thrombosis on NCCT.

Decision Making and the Limits of Evidence A Case Study of Acute Stroke in Pregnancy

We report the case of a pregnant woman treated for acute ischemic stroke and review the literature on acute stroke treatment in pregnancy. To our knowledge, this is the first case reporting the successful use of intravenous tissue plasminogen activator and a stent retriever for acute stroke in pregnancy. We then use this case to consider the way medical knowledge is used in therapeutic decision making and argue that decision making necessarily extends beyond the limits of clinical trial evidence.

Endovascular glue embolization of a radiation-induced lenticulostriate artery pseudoaneurysm in a pediatric patient with optic pathway glioma: Case report and review of literature

Radiation-associated vascular changes most commonly present in the form of stenosis, thrombosis and occlusion. However, development of intracranial aneurysms secondary to radiation is far less common and often manifests with rupture. These aneurysms are difficult to treat and associated with high morbidity and mortality when ruptured compared with saccular aneurysms unrelated to radiation treatment. Both surgical and endovascular options are available for treatment of these aneurysms. We present a young patient with a radiation-induced intracranial pseudoaneurysm arising from the lenticulostriate branch of the left middle cerebral artery (MCA); this developed 1 year 4 months after 59.4u2009Gy of focused radiation to the suprasellar pilomyxoid astrocytoma. The patient successfully underwent endovascular glue embolization of the aneurysm and occlusion of the lenticulostriate artery after unsuccessful trapping of the aneurysm and occlusion of the parent artery using coils. She developed transient hemiparesis of the right side following the procedure, which was managed conservatively. We performed a complete review of the literature dealing with the radiation-induced intracranial aneurysms, their presentation, treatment and outcome.

Stent-assisted coiling of posterior inferior cerebellar artery aneurysm complicated by arterial avulsion

Background Rapid development of new devices and techniques in endovascular neurosurgery allows treatment of complex intracranial vascular lesions. These treatments, however, are not without risk. We report a case of unusual vascular laceration during stent-assisted coiling of a posterior inferior cerebellar artery (PICA) aneurysm. Case presentation A 75-year-old female with a recurrent, previously coiled PICA aneurysm developed avulsion of the parent vessel followed by fatal bleeding while an attempt was made to place a microcatheter across the aneurysmal neck for stent-assisted coiling. Conclusions Pathological examination was performed to understand the mechanism of the rupture. The most likely mechanism was straightening of the significant vascular tortuosity, excessive tension on the vessel origin and avulsion upon advancement of the microcatheter over the microguidewire.

Calcified embolus mimics patent middle cerebral artery on CT angiogram

A 61-year-old woman presented with acute symptoms of right middle cerebral artery ischaemia, with left face/arm/leg weakness, right gaze preference and homonymous hemianopia. A non-contrast CT scan of the head showed a calcified Y-shaped hyperdensity at the right middle cerebral artery bifurcation (figure 1A). We did not identify any contraindications for thrombolytic therapy, and the patient was treated with intravenous tissue plasminogen activator.nnnnFigure 1 nHyperdense calcific thrombus at the right middle cerebral artery bifurcation.nnnnWe used a multi-phase CT angiogram to assess her cerebrovascular status. We expected a role for endovascular intervention given the clinical deficits and corresponding right middle cerebral artery bifurcation hyperdensity, which we assumed to be thrombus. However, the initial phase of the CT angiogram did not show the expected occlusion …

Serpiginous cranial arterial calcification in uremia

A 65-year-old man with chronic kidney disease (CKD) on hemodialysis presented with a subcortical stroke. Unenhanced CT scan of the brain revealed widespread arterial calcification, notably involving the carotid siphons (figure 1) and external carotid artery branches (figure 2, A and B). Vascular calcification in CKD closely resembles ossification, and may involve the intima (as in atherosclerosis) or more commonly the media.1 Both patterns of calcification are associated with increased cardiovascular mortality, though no specific treatment has been shown to modify this risk.2 This example is particularly striking for the serpiginous appearance of the affected arteries.

Dual-stent retrieval for mechanical thrombectomy of refractory clot in acute stroke as a rescue technique

Stroke is a major public health problem worldwide and is the third most expensive health condition in developed countries. More than 80% of strokes are thromboembolic ischemic, with the rest hemorrhagic. About 20% to 30% of all acute ischemic strokes are caused by large intracranial vessel occlusion