Dikran Mardighian

Ruptured Aneurysm in Sphenoid Sinus: Which Is the Best Treatment?

Internal carotid artery (ICA) aneurysms involving the sphenoid sinus are uncommon, and their optimal treatment remains debated. We report the case of a patient presenting with recurrent epistaxis due to a bleeding cavernous ICA aneurysm. We suggest a combined endovascular and endoscopic approach when ICA occlusion may not be performed.

New oral anticoagulants and pituitary apoplexy.

Sir, we report the case of a 76-year-old woman that came to our attention 6 days after the sudden onset of severe headache, followed by drowsiness, visual impairment and right ophthalmoplegia. Five days prior to clinical onset, she had been initiated under an anticoagulation regimen with dabigatran, due to a recent diagnosis of atrial fibrillation. Her medical history included a non-secreting pituitary macroadenoma, incidentally diagnosed and followed for 12 years with serial MRIs, which had documented a slow growth, without any significant optic chiasm compression. On admission the patient presented with a right III nerve palsy and partial bi-temporal hemianopia; therapy with hydrocortisone had already been initiated at another institution and her headache, drowsiness and hyponatremia had significantly improved. Serum sodium was 138 mmol/L, potassium 3.8 mmol/L, plasmatic calcium 7.4 mg/dL, total white blood cells 12.600 lL, hemoglobin 10.7 g/dL, platelets 156.000 l/L. Hormonal pituitary profiling revealed a slight decrease in thyroid secreting hormone and fT3. Radiological investigations documented a dimensional increase of the known pituitary adenoma compared to earlier imaging, extending laterally towards the right cavernous sinus; signs of recent intra-tumoral hemorrhage were evident (Fig. 1) [1, 2]. With the objective of increasing the chances of complete recovery, the patient underwent removal of the hemorrhagic adenoma, achieved through an endoscopic endonasal trans-sphenoidal approach. At surgery the adenoma appeared bluish and soft. On the right side it was possible to see the medial wall of the cavernous sinus without any signs of tumoral invasion. Histology documented a tumor organized in nests, lobules and trabeculae of cells with small nuclei and abundant cytoplasm. Proliferation index MIB1/Ki67 was inferior to 1 %. The neoplasia appeared highly vascularized with hemorrhagic areas, confirming pituitary apoplexy (PA). Patient’s post-operative course was uneventful. Vision and third cranial nerve palsy rapidly recovered in the first week following surgery. Her pituitary function was normal at three-months follow-up and pituitary MRI confirmed the complete removal of the pituitary adenoma. Pituitary apoplexy (PA) is a clinical syndrome characterized by the sudden onset of headache, vomiting, visual impairment, neuro-ophthalmic deficits and decreased consciousness caused by hemorrhage of the pituitary gland or, more frequently, of a pituitary adenoma. PA is relatively rare, but diagnosis is usually straightforward [2]. Among the known risk factors for PA, anticoagulation is one of the most important. The recent development of new anticoagulants such as dabigatran, brought a considerable improvement in the management and quality of life of patients necessitating anticoagulation. Dabigatran belongs to a new class of anticoagulants, being a direct thrombin inhibitor [3, 4]. It has a fast onset of action and a F. Doglietto (&) E. Costi M. M. Fontanella Division of Neurosurgery, Department of Medicine and Surgery, University of Brescia, Largo Spedali Civili, 1, 25123 Brescia, Italy e-mail: francesco.doglietto@unibs.it

Grange syndrome: An identifiable cause of stroke in young adults

Grange syndrome is a disorder characterized by arterial occlusive disease, hypertension, congenital cardiac defects, bone fragility, brachysyndactyly, and learning disabilities. It was first described in four members of the same family and in two sporadic cases thereafter, suggesting the possibility of various patterns of inheritance. We report on the case of an 18‐year‐old female presenting with subarachnoid hemorrhage due to the rupture of a basilar artery aneurysm, and with distinctive systemic features including extensive vasculopathy, facial dysmorphisms and brachysyndactyly, consistent with the diagnosis of Grange syndrome. Although rare and not fully characterized, Grange syndrome should be included in the differential diagnosis of stroke at young age.

CEREBRAL SMALL RESISTANCE ARTERY STRUCTURE AND CEREBRAL BLOOD FLOW IN NORMOTENSIVE SUBJECTS AND IN HYPERTENSIVE PATIENTS: 3D.01

We have previously demonstrated that, in essential hypertensive patients, subcutaneous small resistance artery structural alterations, as indicated by an increased media to lumen ratio (M/L), may predict coronary (J Hypertens 2003;21:625–631) and forearm (J Hypertens 1995;13:341–347) flow reserve. In essential hypertension also human cerebral small arteries present a clear increase in M/L (Rizzoni D et al, J Hypertens 2009; 27:838–845). However, there is no available demonstration about the presence of a direct relationship between cerebral blood flow and cerebral small resistance artery structure. Patients and Methods: Ten subjects were included in the present study. They were 5 hypertensive patients (HP) and 5 normotensive control subjects (NS). All subjects underwent a neurosurgical intervention (trauma, meningioma, etc.). A small portion of morphologically normal cerebral tissue was excised and rapidly put in chilled physiological saline solution. Cerebral small resistance arteries (relaxed diameter around 200 μm) were dissected and mounted on an isometric myograph, and the tunica media to internal lumen ratio was measured (M/L). Before surgical intervention we have also investigated cerebral blood flow (CBF) in different areas (cortex, lenticular nucleus, thalamus and subcortical white matter) by means of dynamic susceptibility contrast (DSC) MR imaging with bolus injection of gadolinium, focusing on specific regions of interest. Results: Are summarized in the Table (*=p < 0.05; ***p < 0.001 vs. NS). Figure 1. No caption available. A statistically significant inverse correlation was observed between M/L of cerebral arteries and CBF in the lenticular nucleus (r=−0.80, p < 0.01) and with CBF in the thalamus (r = −0.75, p < 0.01), while correlation with CBF in the cortex and in the subcortical white matter were not statistically significant (r = −0.21 and −0.21, respectively). Conclusions: Our results indicate that cerebral small artery structure might play a major role in controlling CBF, and this might help to explain the relevant role of structural alterations of small resistance arteries in predicting cerebrovascular events (Circulation 2003;108:2230–2235).

Endovascular Treatment of Acute Basilar Artery Occlusion: Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) Study Group Experience

BACKGROUND Acute basilar artery occlusion (BAO) is considered among the most severe medical emergencies, with very high morbidity and mortality. The aims of this study are to present 5 years experience of 12 centers in Lombardy region on BAO endovascular treatment and to evaluate prognostic factors that may improve clinical outcomes and recanalization rates. MATERIALS AND METHODS Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) registry is a retrospective multicentric collection of patients with acute BAO who underwent endovascular treatment between 2010 and 2015. A total of 102 patients (mean age 65 years) were included. Clinical, procedural, and neuroradiological data were collected. Angiographic results (Treatment in Cerebral Ischemia scale [TICI] score 2b-3) were assessed by each centers interventional neuroradiologist. Good clinical outcome was considered as a modified Rankin Scale score ranging between 0 and 2 in a 3-month follow-up. RESULTS Thirty-nine percent of patients showed good clinical outcome at 3 months. Mortality rate was 30%. TICI 2b-3 was achieved in 62% of patients. Univariate analysis showed that age, National Institutes of Health Stroke Scale (NIHSS) at onset, time to recanalization, and TICI score were all statistically significant clinical outcome predictors (P < .05). Multivariate logistic regression showed that time to recanalization, age, and NIHSS at onset were significant independent predictors of good outcome. CONCLUSIONS BAO treatment needs more efforts to assure patients better clinical outcomes. Mechanical thrombectomy is feasible and effective in patients with acute BAO. These results must be confirmed by further prospective studies within randomized controlled settings.

Short-term outcome of carotid dissecting pseudoaneurysm: is it always benign?

A 35-year-old male was admitted to the Emergency Department because of major head trauma. Brain CT showed acute subdural hematoma and right temporal pole parenchymal hemorrhage. He was intubated for airway protection but was extubated successfully soon thereafter. After sedation withdrawal, the neurological examination showed a deficit of the 9th, 10th, 11th, and 12th cranial nerves as well as Horner’s sign, consistent with left Villaret syndrome. Cerebral magnetic resonance angiography displayed left extracranial internal carotid artery dissection along with a dissecting pseudoaneurysm (DP), causing compression of the lower 4 cranial nerves and sympathetic fibers and 80% lumen stenosis (Fig. 1a). Acetylsalicylic acid 100 mg daily was started after the resolution of the hemorrhagic lesions, 1 month after the acute event. At 3-month followup evaluation, we observed improvement of compressive signs, whereas neuroimaging indicated no further expansion of the vascular lesion (Fig. 1b). Five months later the patient was re-admitted because of acute onset non-fluent aphasia. Brain magnetic resonance showed acute left insular and frontal ischemic lesions, likely of embolic etiology, whereas cerebral angiography showed partial thrombosis of the pseudoaneurysm with persistent blood flow (Figs. 1c, 2). The patient underwent endovascular treatment with Streamline Surpass Stryker flow-diverter device, followed by dual antiplatelet treatment (Acetylsalicylic acid 100 mg daily and Clopidogrel 75 mg daily). The procedure was well tolerated and the patient discharged with unremarkable neurologic examination 3 days later. The incidence of pseudoaneurysm complicating arterial dissection has been reported to range between 13 and 49% [1–3]. The long-term outcome of this conditions is benign in the majority of cases regardless of location, size, and morphology of the pseudoaneurysm and does not implicate an increased propensity to cerebral ischemia, at least in patients receiving antithrombotic medication with anticoagulants or antiplatelet agents [4, 5]. Nevertheless, some Authors recommend surgical or endovascular treatment of DPs in exceptional circumstances, to reduce the risk of rupture or thrombo-embolization. This is the case of large size lesions or of DPs expanding over time, which indicates a dynamic process [2]. In this regard, there are some red flags in our case that are worth considering when managing patients with DPs. Because of the large size of the pseudoaneurysm and cranial nerves compression, endovascular management would have been warranted in our patient in the acute phase. Though we do not dispute this indication, we opted for a conservative approach in order to prevent the potential effect of dual antiplatelet treatment (to be started before the procedure and continued thereafter) on the expansion of the concomitant cerebral hematomas. The lack of further clinical events with improvement of compressive signs as well neuroimaging features indicating no evolution of the vascular lesion and no signs of embolization prompted us to confirm this indication at 3-month follow-up, based on the assumption that any dynamic process of DP progression was over. The occurrence of a thromboembolic event 6 months after the major trauma, however, emphasizes that, in spite of the theoretically low risk of complications of DPs out of the acute phase [4, 5], these conditions cannot be considered completely stable even time after their development. Furthermore, although the pathophysiology of post-traumatic * Loris Poli loris.poli@gmail.com