Eric M. Deshaies

Emergency decompressive craniectomy for fulminating infectious encephalitis.

In patients who develop fulminant cerebral edema and elevated intracranial pressures, viral encephalitis can result in devastating neurological and cognitive sequelae despite antiviral therapy. The benefits of decompressive craniectomy, if any, in this group of patients are unclear. In this manuscript, the authors report their experience with 2 patients who presented with herpes simplex virus requiring surgical decompression resulting in excellent neurocognitive outcomes. They also review the literature on decompressive craniectomy in patients with fulminating infectious encephalitis. Four published articles consisting of 13 patients were identified in which the authors had reported their experience with decompressive craniectomy for fulminant infectious encephalitis. Herpes simplex virus was confirmed in 6 cases, Mycoplasma pneumoniae in 2, and an unidentified viral infection in 5 others. All patients developed clinical signs of brainstem dysfunction and underwent surgical decompression resulting in good (Glasgow Outcome Scale [GOS] Score 4) or excellent (GOS Score 5) functional recoveries. The authors conclude that infectious encephalitis is a neurosurgical disease in cases in which there is clinical and imaging evidence of brainstem compression. Surgical decompression results in excellent recovery of functional independence in both children and adults despite early clinical signs of brainstem dysfunction.

An update on the management of pseudotumor cerebri

Pseudotumor cerebri, or benign intracranial hypertension, is characterized by intracranial hypertension of unknown etiology typically in obese women <45 years of age, and can be disabling secondary to headaches and visual disturbances. Medical management includes pharmaceuticals that reduce cerebrospinal fluid (CSF) production and lumbar punctures that reduce the CSF volume, both aimed at reducing intracranial pressure. When medical management fails, surgical CSF diverting procedures are indicated. Recently it has been demonstrated that dural sinus stenosis or thrombosis can be responsible for this disease and treated with endovascular venous stent placement. The intent of this educational manuscript is to review the clinical presentation of pseudotumor cerebri patients and discuss the medical, surgical, and endovascular treatment options for this disease. After reading this paper, the reader should be able to: (1) understand the pathophysiological basis of pseudotumor cerebri, (2) describe its presenting signs and symptoms, and (3) discuss the medical, surgical, and endovascular treatment options.

Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke: Primary Results of the STRATIS Registry

Background and Purpose— Mechanical thrombectomy with stent retrievers has become standard of care for treatment of acute ischemic stroke patients because of large vessel occlusion. The STRATIS registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) aimed to assess whether similar process timelines, technical, and functional outcomes could be achieved in a large real world cohort as in the randomized trials. Methods— STRATIS was designed to prospectively enroll patients treated in the United States with a Solitaire Revascularization Device and Mindframe Capture Low Profile Revascularization Device within 8 hours from symptom onset. The STRATIS cohort was compared with the interventional cohort of a previously published SEER patient-level meta-analysis. Results— A total of 984 patients treated at 55 sites were analyzed. The mean National Institutes of Health Stroke Scale score was 17.3. Intravenous tissue-type plasminogen activator was administered in 64.0%. The median time from onset to arrival in the enrolling hospital, door to puncture, and puncture to reperfusion were 138, 72, and 36 minutes, respectively. The Core lab–adjudicated modified Thrombolysis in Cerebral Infarction ≥2b was achieved in 87.9% of patients. At 90 days, 56.5% achieved a modified Rankin Scale score of 0 to 2, all-cause mortality was 14.4%, and 1.4% suffered a symptomatic intracranial hemorrhage. The median time from emergency medical services scene arrival to puncture was 152 minutes, and each hour delay in this interval was associated with a 5.5% absolute decline in the likelihood of achieving modified Rankin Scale score 0 to 2. Conclusions— This largest-to-date Solitaire registry documents that the results of the randomized trials can be reproduced in the community. The decrease of clinical benefit over time warrants optimization of the system of care. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT02239640.

Tri-axial system using the Solitaire-FR and Penumbra Aspiration Microcatheter for acute mechanical thrombectomy

The Solitaire-FR (eV3/Covidien, Irvine, CA, USA) retrievable stent (SFR), designed for mechanical thrombectomy in acute ischemic stroke, recently received Food and Drug Administration approval in the USA. Clot retrieval is performed by deploying the SFR through a microcatheter directly into the thrombus, to capture the clot and restore perfusion. In order to perform this maneuver, a balloon guide catheter must be used to apply negative suction and reverse flow within the cervical arteries, thus minimizing the chance of antegrade blood flow dislodging the thrombus from the stent. This technique requires at least an 8-French system that can increase the risk of arterial injury at the access site particularly in older patients with smaller or highly atherosclerotic peripheral arteries, and may provide inadequate aspiration in the vertebrobasilar system where only one vertebral artery is accessed and aspirated. The author describes a technique whereby a 6-French tri-axial system is used to deliver the SFR through a Penumbra Aspiration Microcatheter (Penumbra, Inc., Alameda, CA, USA) to provide intracranial aspiration in close proximity to the stent.

Significant increases of pituitary tumors and resections from 1993 to 2011

Pituitary tumors comprise 10% to 15% of all diagnosed intracranial tumors; 90% are adenomas. Though benign, significant morbidity via compression of surrounding structures or aberrant hormone secretion can occur. This study investigated rates of pituitary tumor diagnoses and treatment trends from 1993 to 2011.

Onyx embolization of a thoracolumbar perimedullary spinal arteriovenous fistula in an infant presenting with subarachnoid and intraventricular hemorrhage

Identifying a source of spontaneous subarachnoid hemorrhage (SAH) or intraventricular hemorrhage (IVH) in patients with negative results on cranial angiographic imaging can be a diagnostic challenge. The authors present the case of a 14-month-old girl who presented with lethargy and spontaneous SAH and IVH, and later became acutely paraplegic. Except for the SAH and IVH, findings on neuroimages of the brain were normal. Magnetic resonance imaging revealed an intramedullary thoracolumbar spinal cord hemorrhage that was found to be associated with arterialized veins intraoperatively. Catheter-based diagnostic angiography identified a spinal perimedullary macroarteriovenous fistula (macro-AVF) that was completely embolized with Onyx, negating the need for further surgical intervention. The authors believe this to be the first reported case of a thoracolumbar perimedullary macro-AVF presenting with SAH and IVH. In addition, descriptions of Onyx embolization of a spinal AVF in the literature are rare, especially in pediatric patients.

Early experience with stent retrievers and comparison with previous-generation mechanical thrombectomy devices for acute ischemic stroke

UNLABELLED OBJECT.: There is limited information regarding patient outcomes following interventions for stroke during the window for endovascular therapy. Studies have suggested that recently approved stent retrievers are safer and more effective than earlier-generation thrombectomy devices. The authors compared cases in which the Solitaire-FR device was used to those in which a MERCI or Penumbra device was used. METHODS This study is a single-center retrospective review of 102 consecutive cases of acute stroke in which patients were treated with mechanical thrombectomy devices between 2007 and 2013. Multivariate models, adjusted for confounding factors, were used to investigate functional independence (modified Rankin Scale [mRS] score ≤ 2, and successful reperfusion (thrombolysis in cerebral infarction [TICI] score ≥ 2b). RESULTS Thrombectomy device had a significant impact on functional independence (mRS score ≤ 2) at discharge from the hospital (p = 0.040). Solitaire-FR treatment resulted in significantly more patients being discharged as functionally independent in comparison with MERCI treatment (p = 0.016). A multivariate model found the use of Solitaire-FR to improve the odds of good clinical outcome in comparison with prior-generation devices (OR 6.283, 95% CI 1.785-22.119, p = 0.004). Additionally, the use of Solitaire-FR significantly increased the odds of successful reperfusion (OR 3.247, 95% CI 1.160-9.090, p = 0.025). CONCLUSIONS The stent retriever Solitaire-FR significantly improved the odds of functional independence and successful revascularization of the arterial tree. New interventional technology for stroke continues to mature, but randomized trials are needed to establish the actual benefit to specific patient populations.

Aneurysm embolization grade: a predictive tool for aneurysm recurrence after coil embolization

BackgroundCoil embolization has gained importance in the management of intracranial aneurysms over the past decade. However, the recurrence risk after embolization mandates closer follow-up than surgical clip ligation. Currently, there is no reliable system for predicting aneurysm sac thrombosis. An aneurysm embolization grade (AEG) reported previously by the senior author (EMD) has been proposed as a tool for predicting the durability of aneurysm occlusion based on hemodynamic characteristics. Here, we present our internal validity results.MethodsAEG and Raymond–Roy Occlusion Classification (RROC) scores were prospectively assigned to all aneurysms coiled from June 2008 to June 2011. The prospectively assigned AEG and RROC scores from the cerebral angiograms were collected for data analysis and validity assessment of the AEG system. 110 consecutive patients who had aneurysm coil embolization were included in this study.ResultsThe post-coiling AEG significantly predicted follow-up angiographic filling characteristics. Pairwise comparisons revealed that the follow-up AEG for those initially scored ‘A’ (complete obliteration) was significantly better than the contrast-flow groups. Significant differences were also noted between contrast-stasis and contrast-flow groups. A pairwise comparison between RROC scores demonstrated that only the RROC Type 1 could be used to predict follow-up occlusion durability. Stent placement in wide-neck aneurysms had no effect on initial AEG, RROC, or long-term occlusion durability. Packing density significantly predicted initial AEG and RROC, but had no effect on long-term occlusion.ConclusionsThe AEG system is uniquely based on angiographic filling characteristics of the aneurysm, and this study demonstrated its high predictive value for determining aneurysm sac thrombosis. Assigning an AEG to the aneurysm can guide the neurointerventionalist in discussions with the patient regarding the probability of aneurysm recurrence and potential need for retreatment.

Stenting versus Endarterectomy and the Impact of Ultra-early Revascularization for Emergent Admissions of Carotid Artery Stenosis

BACKGROUND The factors influencing outcomes after emergent admission for symptomatic carotid artery stenosis treated with revascularization by endarterectomy or stenting are yet to be fully elucidated. METHODS We analyzed revascularization of carotid artery stenosis for patients admitted emergently using the Nationwide Inpatient Sample (2008-2011). Admission characteristics, economic measures, in-hospital mortality, and iatrogenic stroke were compared between (1) endarterectomy and stenting, (2) patients with and without cerebral infarction, and (3) ultra-early (within 48 hours of admission) and deferred (up to 2 weeks) intervention. RESULTS 72,797 admissions meeting our inclusion criteria were identified. Factors associated with ultra-early revascularization were male patients, low comorbidity burden, stenosis without infarction, and stenting. Ultra-early intervention significantly decreased cost and length of stay, and stenting for patients without infarction decreased length of stay but increased cost. Patients without infarction treated within 48 hours had significantly lower mortality and iatrogenic stroke rate. Patients with infarction receiving ultra-early revascularization had increased odds of mortality and iatrogenic stroke in comparison with the deferred group. Patients with infarction receiving stenting experienced increased odds of mortality in comparison with those receiving endarterectomy, but there was no significant difference in iatrogenic stroke rate. Recombinant tissue plasminogen activator (rtPA) administration on the day of revascularization greatly increased the odds of iatrogenic stroke and mortality. CONCLUSIONS Larger prospectively randomized trials evaluating the optimum timing of revascularization after emergent admission of carotid artery stenosis seem warranted.

Enterprise stent for waffle-cone stent-assisted coil embolization of large wide-necked arterial bifurcation aneurysms.

Background: Large wide-necked arterial bifurcation aneurysms present a unique challenge for endovascular coil embolization treatment. One technique described in the literature deploys a Neuroform stent into the neck of the aneurysm in the shape of a waffle-cone, thereby acting as a scaffold for the coil mass. This case series presents four patients with large wide-necked bifurcation aneurysms treated with the closed-cell Enterprise stent using the waffle-cone technique. Case Description: Four patients (59 ± 18 years of age) with large wide-necked arterial bifurcation aneurysms (three basilar apex and one MCA bifurcation) were treated with the waffle-cone technique using the Enterprise stent as a supporting device for stent-assisted coil embolization. Three of the patients presented with aneurysmal subarachnoid hemorrhage (Hunt-Hess 2-3; Fisher Grade 3-4). There was no procedural morbidity or mortality associated with treatment itself. One aneurysm was completely obliterated, and three had small residual necks. One patient developed an area of PCA infarct and visual field cut one month after the procedure and required recoiling of the residual neck. The flared ends of the Enterprise stent remodeled the aneurysm neck by conforming to the shape of the neck without any technical difficulty, resulting in a stable scaffold holding the coils into the aneurysm. Conclusion: The closed cell construction, flexibility, and flared ends of the Enterprise stent allow it to conform to the waffle-cone configuration and provide a stable scaffold for coil embolization of large wide-necked arterial bifurcation aneurysms. We have had excellent initial results using the Enterprise stent with the waffle-cone technique. However, this technique is higher risk than standard treatment methods and therefore should be reserved for large wide-necked bifurcation aneurysms where Y stenting is needed, but not possible, and surgical clip ligation is not an option.