Horia Marin

Intracranial angioplasty and stent placement for direct cerebral revascularization of nonacute intracranial occlusions and near occlusions

OBJECT The authors reviewed their experience in 7 cases of nonacute intracranial occlusions and near occlusions in which the patients underwent intracranial angioplasty and stent implantation for direct cerebral revascularization. METHODS Between 2005 and 2008, 4 men and 3 women underwent direct cerebral revascularization of nonacute intracerebral occlusions or near occlusions. Five patients had chronic angiographically documented occlusion and 2 patients had chronic angiographically documented near occlusions. The locations of the treated vessels included 2 supraclinoid internal carotid arteries, 4 middle cerebral arteries, and 1 vertebral artery. Prior to intervention, all patients were symptomatic and experienced strokes ipsilateral to their occlusions. In addition, all patients had clinical or radiographic evidence of ongoing hemodynamic compromise. Five patients underwent successful intracranial angioplasty and stent placement and 2 patients underwent successful intracranial balloon angioplasty alone. The mean time from documented vessel occlusion to treatment was 35 days. All patients had successful revascularization determined using the Thrombolysis in Cerebral Infarction (TICI) scale: TICI Score 3, 2b, and 2a in 4, 2, and 1 patient, respectively, and the mean residual stenosis was 38%. RESULTS After uneventful technical procedures, 1 patient suffered a perforator vessel stroke and 1 patient suffered a fatal hemorrhage. Mean modified Rankin Scale score of 2 (range 1-5) and mean Glasgow Outcome Scale score of 4 (range 1-6) were achieved during a mean clinical follow-up period of 399 days (range 1-840 days). Asymptomatic restenosis was documented in 4 patients, 1 underwent bypass retreatment, and 1 patient received repeated balloon angioplasty. CONCLUSIONS Combined intracranial angioplasty and stent placement is a potential treatment option in selected patients for the direct revascularization of nonacute intracranial occlusions and near occlusions. Whether this represents a substantial risk reduction compared with the best medical therapy or a long-lasting treatment option is unknown.

MRI Pre- and Post-Embolization Enhancement Patterns Predict Surgical Outcomes in Intracranial Meningiomas

To evaluate the effects of preoperative embolization on overall surgical outcomes after meningioma resection and determine whether pre‐ and postembolization tumor enhancement patterns on magnetic resonance imaging (MRI) scans can be used to assess the efficacy of embolization.

Glioblastoma and intracranial aneurysms: Case report and review of literature.

Background: There is a paucity of data on the association of glioblastoma multiforme (GBM) with intracranial aneurysms. It is an important clinical entity for physicians to be aware of and its presence illustrates several critical features of the pathophysiology of malignant glioma. In this article we present a case of a middle cerebral artery (MCA) pseudoaneurysm that occurred in a patient with recurrent GBM as well discuss the current literature relating to this unique combination of pathologies. Case Description: The authors present a case of a MCA pseudoaneurysm that developed in a patient with recurrent GBM and discuss the current literature. The authors identified 19 reports describing 23 patients harboring both GBM and an intracranial aneurysm. Conclusion: Several theories stand to explain the coincidental occurrence of intracranial aneurysms and GBM. The treating physician should be aware of this association when patients with intraaxial tumors present with unusual manifestation such as an intratumoral hemorrhage or angiogram negative subarachnoid hemorrhage. No guidelines exist to assist in the management of such patients; therefore, authors have attempted to address this issue using a classification and treatment algorithm.

Case Series: Long segment extra-arachnoid fluid collections: Role of dynamic CT myelography in diagnosis and treatment planning.

We report five patients in whom spinal MRI revealed extra-arachnoid fluid collections. These spinal fluid collections most likely resulted from accumulation of cerebrospinal fluid (CSF) from a dural leak. The patients presented with either compressive myelopathy due to the cyst or superficial siderosis (SS). All of these fluid collections were long segment, and MRI demonstrated the fluid collections but not the exact site of leak. Dynamic CT myelogram demonstrated the site of leak and helped in the management of these complicated cases. Moreover, we also found that the epicenter of the fluid collection on MRI was different from the location of the leak on a dynamic CT myelogram. Knowledge of these associations can be helpful when selecting the imaging studies to facilitate diagnosis and treatment.

Spontaneous resolution of a flow-related ophthalmic-segment aneurysm after treatment of anterior cranial fossa dural arteriovenous fistula.

Background: The natural history of proximal, feeding-artery aneurysms after successful obliteration of high-grade, anterior cranial fossa dural arteriovenous fistulas (dAVFs) has not been well documented. Case Description: A 52-year-old Caucasian male presented with an unruptured anterior cranial fossa (dAVF) and an associated aneurysm. Cerebral angiography revealed a large, contralateral, carotid-ophthalmic segment aneurysm, enlarged feeding ophthalmic arteries, as well as cortical venous drainage. Successful surgical obliteration of the dAVF was undertaken to eliminate the risk of hemorrhage. Conclusion: The carotid-ophthalmic aneurysm regressed significantly after surgical obliteration of the dAVF and a follow-up, planned coiling procedure to address the carotid-ophthalmic aneurysm was abandoned. This represents the first reported case of a near complete, spontaneous resolution of an unruptured carotid-ophthalmic aneurysm associated with a high-grade anterior cranial fossa dAVF.

Cerebrovascular Imaging (CT, MRI, CTA, MRA)

There are a number of imaging modalities available for evaluating the vasculature of the head and neck, each of which has its own advantages and disadvantages for evaluating various disease processes. Thus, the clinical scenario and clinical question must be considered in choosing the most appropriate imaging modality. This chapter will focus on MR and CT techniques for cerebrovascular imaging and will include discussion about both the technical aspects as well as imaging findings of various pathologic processes.

CSF Pressure Change in Relation to Opening Pressure and CSF Volume Removed

BACKGROUND AND PURPOSE: Idiopathic intracranial hypertension is a complex neurologic disorder resulting from increased intracranial pressure. Our aim was to determine whether a correlation exists between the CSF pressure-volume relationship, specifically the craniospinal elastance and pressure-volume index, in patients with idiopathic intracranial hypertension and whether opening pressure affects this relationship. MATERIALS AND METHODS: Lumbar punctures performed for suspected idiopathic intracranial hypertension from 2006 to 2017 were identified. Opening and closing pressures, CSF volume removed, and clinical diagnosis of idiopathic intracranial hypertension were obtained from the medical records. The craniospinal elastance (pressure change per milliliter of CSF removed) and pressure-volume index were calculated, and the Pearson correlation coefficients between both the craniospinal elastance and pressure-volume index and opening pressure were determined. Linear regression models of craniospinal elastance and the pressure-volume index and interaction terms with opening pressure were assessed for covariate influence on this association. RESULTS: One hundred sixteen patients were included in the final analysis. The mean craniospinal elastance according to opening pressure group was 0.52 ± 0.18 for <20 cm H2O, 0.57 ± 0.20 for 20–29 cm H2O, 0.91 ± 0.28 for 30–39 cm H2O, and 1.20 ± 0.25 for ≥40 cm H2O. There was a positive linear association between opening pressure and craniospinal elastance with a 0.28 cm H2O/mL increase in craniospinal elastance (standard error = 0.03, P < .001) for every 10 cm H2O increase in opening pressure. Of the covariables analyzed, only age older than 50 years and total volume of CSF removed affected this association. CONCLUSIONS: As opening pressure increases, the craniospinal elastance increases in a linear fashion while the pressure-volume index decreases. Further studies are needed to determine whether these changes relate to the underlying pathophysiology of idiopathic intracranial hypertension or simply represent established CSF volume pressure dynamics.

Cord Topographical Anatomy and its Role in Evaluating Intramedullary Lesions

Intramedullary spinal lesions present a wide differential diagnosis including infectious, inflammatory, traumatic, ischemic, benign, or malignant neoplastic etiologies. Using knowledge of anatomy and physiology within the spinal cord, many similar appearing entities can be parsed into a prioritized differential. The purpose of this article is to review anatomy and pathophysiology of the spinal cord, with subsequent discussion of how this knowledge can be used to differentiate several similar appearing intramedullary pathologic processes. Discussion includes the pathophysiology, imaging findings, and clinical pearls of several intramural lesions including infarct, demyelinating lesions, traumatic injury, neoplasm, vascular malformation, and metabolic processes such as subacute combined degeneration.

Creating accountable care for carotid angioplasty and stenting: A multidisciplinary carotid revascularization board.

Background: We tested the feasibility of a mandated multidisciplinary carotid revascularization board (MDCB) to review, approve and monitor all carotid artery and stenting (CAS) procedures and outcomes at our institution. Methods: The board was composed of vascular surgeons, cardiologists, interventional neuroradiologists, neurosurgeons, and neurologists, who met weekly to facilitate an evidence-based, consensus recommendation to ensure appropriate CAS referral. Results: The board successfully reviewed and continues to review and approve all CAS procedures at our center. Of the 69 patients considered high risk for standard surgical treatment, 42 patients were symptomatic and 27 patients were asymptomatic. Their mean age was 70.5-year-old and the median degree of stenosis was 79%. In the 74 procedures, periprocedural complications occurred at the following rates: 2.7% death, 2.7% major stroke, 2.7% minor stroke, and 2.7% myocardial infarction (MI) within 30 days of the procedure. At 1 year the primary endpoints of ipsilateral stroke and neurovascular-related death were observed in 8.1% and 2.7% of the patients, respectively. At mean follow-up of 21 months, 18.8% of the patients (13/69) had died (including all causes), and 14.5% (10/69) experienced stroke (including nontarget strokes). Target vessel revascularization was needed in 2.9% patients. Conclusions: A mandated multidisciplinary carotid revascularization board MDCB is feasible and potentially advantageous in real clinical practice. It establishes a model for accountable care by providing a mechanism for institutional oversight, credentialing operators, quality review, standardizing care, cost containment and eliminating the “subspecialty silo mentality.”