Howard Lesiuk

Canadian Registry of LVIS Jr for Treatment of Intracranial Aneurysms (CaRLA)

Introduction Stents reduce the rate of angiographic recurrence of intracranial aneurysms. The newest stent for intracranial use is the Low-profile Visible Intraluminal Support device (LVIS Jr). Objective To assess the efficacy of the new stent in a multicenter retrospective registry. Materials and method Centers across Canada using LVIS Jr were contacted and asked to participate in a retrospective registry of consecutive patients treated with LVIS Jr for intracranial aneurysms between January 2013 and July 2015. Results A total of 102 patients, with saccular aneurysms in 100 patients (72 women; age range 21–78 years; mean 56.0 years; median 57.5 years) were treated with a LVIS Jr stent. The mean maximum diameter of the dome and neck of the aneurysm and dome to neck ratios were 8.3 mm±7.7 mm, 4.4 mm±1.9 mm, and 1.86±1.22, respectively. Angiographic complications arose in 23 patients, clinical complications in 9 patients, and only 3% of permanent neurological deficits occurred. Death occurred in 1 patient, unrelated to the stent. The ruptured status of the aneurysms (OR=3.29; p=0.046) and use of LVIS Jr for bailout (OR=2.54; p=0.053) showed a trend towards significant association with higher angiographic complications. At the last available follow-up, 68 class I, 20 class II, and 12 class III results were seen. Conclusions The LVIS Jr stent is a safe and effective device for stent-assisted coiling, with 3% permanent neurological complications. Stent-assisted coiling continues to be technically challenging in cases of ruptured aneurysms and bailout situations.

Heparin dosing is associated with diffusion weighted imaging lesion load following aneurysm coiling

Background and purpose Diffusion weighted imaging (DWI) may be used to evaluate post-coiling ischemia. Heparinization protocols for cerebral aneurysm coiling procedures differ among operators and centers, with little literature surrounding its effect on DWI lesions. The goal of this study was to determine which factors, including heparinization protocols, may affect DWI lesion load post-coiling. Materials and methods A review of 135 coiling procedures over 5 years at our centre was performed. Procedural data including length of procedure, number of coils used, stent or balloon assistance and operators were collected. Procedures were either assigned as using a bolus dose (>2000 U at any one time) or small aliquots of heparin (≤2000 U). Postprocedure DWI was reviewed and lesions were classified as small (< 5mm), medium (5–10 mm) or large (>10 mm). The cases were then classified into group 1 (≤5 small lesions) or group 2 (>5 small lesions or ≥1 medium or large lesion). Multivariate regression of the procedural variables for the two groups was calculated. A p value of <0.05 was considered significant. Results There were 78 procedures in group 1 and 57 procedures in group 2. Patients who received small aliquots (n=37) versus boluses of heparin (n=98) intraprocedurally had significantly greater frequency and size of DWI lesions (p=0.03). None of the other procedural variables was found to impact on lesion load. Conclusions More substantial DWI lesions were associated with small aliquots of heparin dosage compared with bolus doses. Heparin boluses should be preferentially administered during aneurysm coiling.

Dolichoectasia of the vertebral basilar and internal carotid arteries: A case report and literature review.

Background: Dolichoectasia is a rare disorder of the cerebral vasculature consisting of vascular elongation, widening, and tortuosity, usually involving the vertebral and basilar arteries. Its neurological symptoms and signs are highly variable. Case Description: We present a case of dolichoectasia of the vertebrobasilar system in a patient with a long standing history of multiple falls. Repeat neuroimaging revealed an increase in size of the dolichoectatic segment. In addition, a new fusiform dilatation of the contralateral petrous segment of the internal carotid artery and isolated ventriculomegaly had developed. Conclusion: Vertebrobasilar dolichoectasia can cause multiple clinical manifestations, with hydrocephalus being less common. In addition, having dolichoectasia of both posterior and anterior circulation is extremely rare.

Primary skull-based yolk-sac tumour: case report and review of central nervous system germ cell tumours.

Primary intra-cranial germ-cell tumours (GCT) are rare and it is important to differentiate them histologically as their prognosis and treatment is quite different. Moreover, highly malignant non-germinomatous GCT (NG GCT) comprise a small portion of these tumours with limited data available on appropriate treatment approaches. We present the case of a 22-year-old male with a unique primary skull-based yolk-sac subtype NG GCT with a literature review of current treatment options. To our knowledge, there have not been any previously published reports of a primary yolk-sac tumour arising from the petrous apex.

Nail gun injuries to the head with minimal neurological consequences: a case series.

BackgroundAn estimated 3700 individuals are seen annually in US emergency departments for nail gun-related injuries. Approximately 45 cases have been reported in the literature concerning nail gun injuries penetrating the cranium. These cases pose a challenge for the neurosurgeon because of the uniqueness of each case, the dynamics of high pressure nail gun injuries, and the surgical planning to remove the foreign body without further vascular injury or uncontrolled intracranial hemorrhage.Case presentationHere we present four cases of penetrating nail gun injuries with variable presentations. Case 1 is of a 33-year-old white man who sustained 10 nail gunshot injuries to his head. Case 2 is of a 51-year-old white man who sustained bi-temporal nail gun injuries to his head. Cases 3 and 4 are of two white men aged 22 years and 49 years with a single nail gun injury to the head. In the context of these individual cases and a review of similar cases in the literature we present surgical approaches and considerations in the management of nail gun injuries to the cranium. Case 1 presented with cranial nerve deficits, Case 2 required intubation for low Glasgow Coma Scale, while Cases 3 and 4 were neurologically intact on presentation. Three patients underwent angiography for assessment of vascular injury and all patients underwent surgical removal of foreign objects using a vice-grip. No neurological deficits were found in these patients on follow-up.ConclusionsNail gun injuries can present with variable clinical status; mortality and morbidity is low for surgically managed isolated nail gun-related injuries to the head. The current case series describes the surgical use of a vice-grip for a good grip of the nail head and controlled extraction, and these patients appear to have a good postoperative prognosis with minimal neurological deficits postoperatively and on follow-up.

Next day discharge after elective intracranial aneurysm coiling: is it safe?

Background There is a paucity of literature on early discharge after elective aneurysm treatment. We hypothesize that patient discharge on the next day is not associated with an increase in post-discharge adverse events. Methods We retrospectively reviewed elective coiling procedures between 2009 and 2013. The primary outcome measure was 30-day adverse events (emergency department visits, readmission or prolonged admission >30 days, and death). We evaluated the association between early and standard discharge for the primary outcome using the Fisher exact test. We also assessed the association of the primary outcome with other patient and technical variables as well as findings on pre-discharge diffusion weighted imaging. Results We included 97 patients. Median length of hospital stay (LOS) was 2.52 days, and in 26 patients (26.8%) LOS was <2 days. There was no significant difference in post-discharge adverse outcome rates between early and standard discharge groups (19.2% vs 18.3%; p=1.000). The primary outcome was significantly associated with the use of flow diverters (p=0.0287) and change in modified Rankin Scale category at discharge (p=0.0329). No significant association was noted between the outcome and the other variables including the presence of diffusion restriction pre-discharge (p>0.05). Conclusions Patient discharge the next day after elective intracranial aneurysm coiling is not associated with an increase in 30-day adverse outcomes. A prospective study investigating early discharge in elective treatment is warranted. Trial number OHSN-REB #20130786-01H.

Clinical prediction of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

OBJECTIVEThe aim of this study was to derive a clinically applicable decision rule using clinical, radiological, and laboratory data to predict the development of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients.METHODSPatients presenting over a consecutive 9-year period with subarachnoid hemorrhage (SAH) and at least 1 angiographically evident aneurysm were included. Variables significantly associated with DCI in univariate analysis underwent multivariable logistic regression. Using the beta coefficients, points were assigned to each predictor to establish a scoring system with estimated risks. DCI was defined as neurological deterioration attributable to arterial narrowing detected by transcranial Doppler ultrasonography, CT angiography, MR angiography, or catheter angiography, after exclusion of competing diagnoses.RESULTSOf 463 patients, 58% experienced angiographic vasospasm with an overall DCI incidence of 21%. Age, modified Fisher grade, and ruptured aneurysm location were significantly associated with DCI. This combination of predictors had a greater area under the receiver operating characteristic curve than the modified Fisher grade alone (0.73 [95% CI 0.67-0.78] vs 0.66 [95% CI 0.60-0.71]). Patients 70 years or older with modified Fisher grade 0 or 1 SAH and a posterior circulation aneurysm had the lowest risk of DCI at 1.2% (0 points). The highest estimated risk was 38% (17 points) in patients 40-59 years old with modified Fisher grade 4 SAH following rupture of an anterior circulation aneurysm.CONCLUSIONSAmong patients presenting with aSAH, this score-based clinical prediction tool exhibits increased accuracy over the modified Fisher grade alone and may serve as a useful tool to individualize DCI risk.

Transient in-stent stenosis at mid-term angiographic follow-up in patients treated with SILK flow diverter stents: incidence, clinical significance and long-term follow-up

Background Little is known about in-stent stenosis (ISS) in patients with aneurysms treated with flow diverter (FD) stents. The reported incidence in the literature varies significantly. Objective The aim of this study was to assess the incidence, severity, distribution, clinical significance, and possible predictors for ISS. Methods Between July 2012 and June 2016 we retrospectively reviewed all patients treated with SILK FDs in our center. Only cases with short-term (4±2 months) and long-term (>1 year) follow-ups with digital subtraction angiograms were included. ISS was graded as mild (<25%), moderate (25–50%) or severe (>50%). The following predictors for ISS were assessed: gender, age, the presence of subarachnoid hemorrhage, aneurysm size, location, occlusion status, and post-stenting angioplasty. Results Thirty-six patients met the inclusion criteria. At mid-term follow-up, ISS was observed in 16/36 patients (44%). Eleven patients (69%) had mild ISS, three (19%) moderate, and two (12%) severe ISS. ISS was diffuse in 11 patients (69%) and focal in five patients (31%). All patients were asymptomatic. Thirteen patients were maintained on dual antiplatelet therapy and three on aspirin alone. At long-term follow-up, complete ISS resolution was seen in 11 patients, improvement in three and worsening in two patients. No de novo ISS occurrence was observed. On univariate analysis there was no significant predictor for ISS. Conclusions Transient ISS after FD deployment is a common asymptomatic finding on mid-term angiographic follow-up. Complete resolution or improvement at long-term follow-up is seen in most patients who are maintained on dual antiplatelet therapy.