Jonathan A. Grossberg

Complications following cranioplasty and relationship to timing: A systematic review and meta-analysis

The optimal timing of cranioplasty after decompressive craniectomy has not been well established. The purpose of this study was to evaluate the relationship between timing of cranioplasty and related complications. A systematic search of MEDLINE, Scopus, and the Cochrane databases was performed using PRISMA guidelines for English-language articles published between 1990 and 2015. Case series, case-control and cohort studies, and clinical trials reporting timing and complication data for cranioplasty after decompressive craniectomy in adults were included. Extracted data included overall complications, infections, reoperations, intracranial hemorrhage, extra-axial fluid collections, hydrocephalus, seizures, and bone resorption for cranioplasty performed within (early) and beyond (late) 90days. Twenty-five of 321 articles met inclusion criteria for a total of 3126 patients (1421 early vs. 1705 late). All were retrospective observational studies. Early cranioplasty had significantly higher odds of hydrocephalus than late cranioplasty (Odds Ratio [OR] 2.38, 95% Confidence Interval [CI] 1.25-4.52, p=0.008). There was no difference in odds of overall complications, infections, reoperations, intracranial hemorrhage, extra-axial fluid collections, seizures, or bone resorption. Subgroup analysis of trauma patients revealed a decreased odds of extra-axial fluid collection (OR 0.30, p=0.02) and an increased odds of hydrocephalus (OR 4.99, p=0.05). Early cranioplasty within 90days after decompressive craniectomy is associated with an increased odds of hydrocephalus than with later cranioplasty, but no difference in odds of developing other complications. Earlier cranioplasty in the trauma population is associated with fewer extra-axial fluid collections.

Treatment of complex anterior cerebral artery aneurysms with Pipeline flow diversion: mid-term results

Background The off-label use of flow diverters in the treatment of distal aneurysms continues to be debated. Objective To report our multicenter experience in the treatment of complex anterior cerebral artery aneurysms with the Pipeline embolization device (PED). Methods The neurointerventional databases of the four participating institutions were retrospectively reviewed for aneurysms treated with PED between October 2011 and January of 2016. All patients treated for anterior cerebral artery aneurysms were included in the analysis. Clinical presentation, location, type, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis. Results Twenty patients (13 female) with 20 aneurysms met the inclusion criteria in our study. Fifteen aneurysms were classified as saccular and five as fusiform (mean size 7.3 mm). Thirteen aneurysms were located in the anterior communicating region (ACOM or A1/2 junction), six were A2-pericallosal, and one was located in the A1 segment. Six patients had presented previously with subarachnoid hemorrhage and had their aneurysms initially clipped or coiled. There was one minor event (a small caudate infarct) and one major event (intraparenchymal hemorrhage). Sixteen of the 20 patients had angiographic follow-up (mean 10 months). Eleven aneurysms were completely occluded, one had residual neck, and four had residual aneurysm filling. Conclusions The treatment of complex anterior cerebral artery aneurysms with the PED as an alternative for patients who are not good candidates for conventional methods is technically feasible and safe. Mid-term results are promising but larger series with long-term follow-up are required to assess its effectiveness.

Endovascular Management vs Intravenous Thrombolysis for Acute Stroke Secondary to Carotid Artery Dissection: Local Experience and Systematic Review.

BACKGROUND Little is known regarding the endovascular management of acute ischemic stroke (AIS) related to carotid artery dissection (CAD). OBJECTIVE To report our interventional experience in AIS from CAD and to compare it with conservative treatment of CAD with intravenous thrombolysis (IVT) via systematic review. METHODS Retrospective analysis of consecutive high-grade steno-occlusive CAD with National Institutes of Health Stroke Scale (NIHSS) >5 and ≤12 hours of last seen normal from 2 tertiary centers. A systematic review for studies on IVT in the setting of CAD via PubMed was performed for comparison. RESULTS Of 1112 patients treated with endovascular interventions within the study period, 21 met the inclusion criteria. Mean age was 52.0 ± 10.9 years, 76% were male, NIHSS was 17.4 ± 5.8, 52% received IVT before intervention, and 90% had tandem occlusions. Mean time from last-known-normal to puncture was 4.8 ± 2.1 hours and procedure length 1.8 ± 1.0 hours. Stents were used in 52% of cases, and reperfusion (modified Treatment in Cerebral Ischemia 2b-3) achieved in 95%. No parenchymal hemorrhages were observed and 71% achieved good outcome (90-day modified Rankin Scale 0-2). The literature review identified 8 studies concerning thrombolysis in the CAD setting fitting inclusion criteria (n = 133). Our endovascular experience compared with the pooled IVT reports indicated that, despite presenting with higher NIHSS (17 vs 14; P = .04) and experiencing a longer time to definitive therapy (287 vs 162 minutes; P < .01), patients treated intra-arterially had similar rates of symptomatic cerebral/European Cooperative Acute Stroke Study-parenchymal hematoma 2 hemorrhage (0% vs 6%; P = .43) and good outcomes (71% vs 52%; P = .05). CONCLUSION Our study provides evidence that the endovascular management of AIS in the setting of CAD is a feasible, safe, and promising strategy.

Endovascular Treatment for Patients With Acute Stroke Who Have a Large Ischemic Core and Large Mismatch Imaging Profile

Importance Endovascular therapy (ET) is typically not considered for patients with large baseline ischemic cores (irreversibly injured tissue). Computed tomographic perfusion (CTP) imaging may identify a subset of patients with large ischemic cores who remain at risk for significant infarct expansion and thus could still benefit from reperfusion to reduce their degree of disability. Objective To compare the outcomes of patients with large baseline ischemic cores on CTP undergoing ET with the outcomes of matched controls who had medical care alone. Design, Setting, and Participants A matched case-control study of patients with proximal occlusion after stroke (intracranial internal carotid artery and/or middle cerebral artery M1 and/or M2) on computed tomographic angiography and baseline ischemic core greater than 50 mL on CTP at a tertiary care center from May 1, 2011, through October 31, 2015. Patients receiving ET and controls receiving medical treatment alone were matched for age, baseline ischemic core volume on CTP, and glucose levels. Baseline characteristics and outcomes were compared. Main Outcomes and Measures The primary outcome measure was the shift in the degree of disability among the treatment and control groups as measured by the modified Rankin Scale (mRS) (with scores ranging from 0 [fully independent] to 6 [dead]) at 90 days. Results Fifty-six patients were matched across 2 equally distributed groups (mean [SD] age, 62.25 [13.92] years for cases and 58.32 [14.79] years for controls; male, 13 cases [46%] and 14 controls [50%]). Endovascular therapy was significantly associated with a favorable shift in the overall distribution of 90-day mRS scores (odds ratio, 2.56; 95% CI, 2.50-8.47; P = .04), higher rates of independent outcomes (90-day mRS scores of 0-2, 25% vs 0%; P = .04), and smaller final infarct volumes (mean [SD], 87 [77] vs 242 [120] mL; P < .001). One control (4%) and 2 treatment patients (7%) developed a parenchymal hematoma type 2 (P > .99). The rates of hemicraniectomy (2 [7%] vs 6 [21%]; P = .10) and 90-day mortality (7 [29%] vs 11 [48%]; P = .75) were numerically lower in the intervention arm. Sensitivity analysis for patients with a baseline ischemic core greater than 70 mL (12 pairs) revealed a significant reduction in final infarct volumes (mean [SD], 110 [65] vs 319 [147] mL; P < .001) but only a nonsignificant improvement in the overall distribution of mRS scores favoring the treatment group (P = .18). All 11 patients older than 75 years had poor outcomes (mRS score >3) at 90 days. Conclusions and Relevance In properly selected patients, ET appears to benefit patients with large core and large mismatch profiles. Future prospective studies are warranted.

Early Endovascular Treatment in Intravenous Tissue Plasminogen Activator–Ineligible Patients

Background and Purpose— Intravenous tissue-type plasminogen activator (tPA) treatment in acute stroke has many exclusion criteria. We aimed to assess the safety and efficacy of endovascular therapy (ET) in intravenous (IV) tPA-ineligible patients. Methods— Retrospective analysis of a prospectively collected database of consecutive patients treated with ET within 6 hours of stroke onset between September 2010 and April 2015. Patients treated with IV-tPA followed by ET were compared with those treated with ET alone because of IV-tPA ineligibility. Efficacy and safety end points included the rates of good outcome (90-day modified Rankin scale score ⩽2), successful reperfusion (modified Treatment in Cerebral Ischemia 2b-3), parenchymal hematoma (PH-1 and PH-2), and 90-day mortality. Univariate and logistic regression were performed to identify the predictors of outcomes. Results— A total of 422 patients were included. Two hundred and fifty-three (59%) patients received IV-tPA+ET, and 169 (41%), ET alone. Combined IV-tPA+ET patients were slightly younger (64.9±15.2 versus 67.9±14.9 years; P=0.05), more often males (56% versus 44%; P=0.01), and had less hypertension (70% versus 81%; P=0.02) and vertebrobasilar occlusions (3% versus 8%; P=0.02). The remaining baseline characteristics, including National Institutes of Health Stroke Scale score (20 [15–23] versus 19 [15–24]; P=0.85), Alberta Stroke Program Early CT Score (ASPECTS; 8 [7–9] versus 8 [7–9]; P=0.24), and stroke onset to puncture times (235±70 versus 240±81 minutes; P=0.27), were similar across both groups. There were no significant differences in the rates of modified Treatment in Cerebral Ischemia 2b-3 (83% versus 80%; P=0.52), 90-day modified Rankin scale score ⩽2 (45% versus 38%; P=0.21), or any PH (3% versus 5%; P=0.21). Unadjusted 90-day mortality was higher with ET alone (21% versus 34%; P<0.01); however, IV-tPA ineligibility was not associated with modified Treatment in Cerebral Ischemia 2b-3, any PH, good outcome, or 90-day mortality on logistic regression. Conclusions— IV-tPA-eligible and -ineligible patients seem to have similar outcomes after early ET.

Age increases the risk of immediate postoperative dysphagia and pneumonia after odontoid screw fixation

INTRODUCTION Type II odontoid fractures are the most common spinal fracture in the elderly population and may be managed with halo immobilization, posterior fusion, and anterior odontoid screw fixation. Anterior odontoid screw fixation has several advantages over posterior fusion, including: reduced surgical time, decreased post-operative pain, preserved range of motion, earlier mobilization, and decreased postoperative narcotic requirement. We review our experience using anterior odontoid screw fixation in type II odontoid fractures in the elderly and non-elderly populations. METHODS Demographic and outcome data were retrospectively collected in 30 consecutive patients with type II odontoid fractures treated with anterior odontoid screw fixation. RESULTS Mean patient age was 70.7 (range 20-92); 18 of the patients were male and 12 were female. All patients had successful placement of a single anterior odontoid screw without intra-operative complication. Complications included pneumonia in nine patients (30%), gastrostomy tube placement due to patient failing swallow evaluation in 13 patients (43%), and vocal cord paralysis in one patient (3.3%). Patients over the age of 75 accounted for 12 of the 13 (92%) gastrostomy tube placements and eight of the nine (88.9%) pneumonias, respectively. The difference in rates of gastrostomy tube placement and pneumonia for the older patients were both found to be statistically significant with P<.0001 for gastrostomy tubes and P<.02 for pneumonias. CONCLUSIONS Anterior odontoid screw fixation is an effective treatment option for patients with Type II odontoid fractures. In the elderly population, however, the benefits of the procedure must be weighed against the risks of postoperative dysphagia requiring gastrostomy and pneumonia.

Early Cranioplasty is Associated with Greater Neurological Improvement: A Systematic Review and Meta-Analysis

BACKGROUND Cranioplasty after decompressive craniectomy is a common neurosurgical procedure, yet the optimal timing of cranioplasty has not been well established. OBJECTIVE To investigate whether the timing of cranioplasty is associated with differences in neurological outcome. METHODS A systematic literature review and meta-analysis was performed using MEDLINE, Scopus, and the Cochrane databases for studies reporting timing and neurological assessment for cranioplasty after decompressive craniectomy. Pre- and postcranioplasty neurological assessments for cranioplasty performed within (early) and beyond (late) 90 d were extracted. The standard mean difference (SMD) was used to normalize all neurological measures. Available data were pooled to compare pre-cranioplasty, postcranioplasty, and change in neurological status between early and late cranioplasty cohorts, and in the overall population. RESULTS Eight retrospective observational studies were included for a total of 528 patients. Studies reported various outcome measures (eg, Barthel Index, Karnofsky Performance Scale, Functional Independence Measure, Glasgow Coma Scale, and Glasgow Outcome Score). Cranioplasty, regardless of timing, was associated with significant neurological improvement (SMD .56, P = .01). Comparing early and late cohorts, there was no difference in precranioplasty neurological baseline; however, postcranioplasty neurological outcome was significantly improved in the early cohort (SMD .58, P = .04) and showed greater magnitude of change (SMD 2.90, P = .02). CONCLUSION Cranioplasty may improve neurological function, and earlier cranioplasty may enhance this effect. Future prospective studies evaluating long-term, comprehensive neurological outcomes will be required to establish the true effect of cranioplasty on neurological outcome.

Automated CT Perfusion Ischemic Core Volume and Noncontrast CT ASPECTS (Alberta Stroke Program Early CT Score) Correlation and Clinical Outcome Prediction in Large Vessel Stroke

Background and Purpose— The semiquantitative noncontrast CT Alberta Stroke Program Early CT Score (ASPECTS) and RAPID automated computed tomography (CT) perfusion (CTP) ischemic core volumetric measurements have been used to quantify infarct extent. We aim to determine the correlation between ASPECTS and CTP ischemic core, evaluate the variability of core volumes within ASPECTS strata, and assess the strength of their association with clinical outcomes. Methods— Review of a prospective, single-center database of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions with pretreatment CTP between September 2010 and September 2015. CTP was processed with RAPID software to identify ischemic core (relative cerebral blood flow<30% of normal tissue). Results— Three hundred and thirty-two patients fulfilled inclusion criteria. Median age was 66 years (55–75), median ASPECTS was 8 (7–9), whereas median CTP ischemic core was 11 cc (2–27). Median time from last normal to groin puncture was 5.8 hours (3.9–8.8), and 90-day modified Rankin scale score 0 to 2 was observed in 54%. The correlation between CTP ischemic core and ASPECTS was fair (R=−0.36; P<0.01). Twenty-six patients (8%) had ASPECTS <6 and CTP core ⩽50 cc (37% had modified Rankin scale score 0–2, whereas 29% were deceased at 90 days). Conversely, 27 patients (8%) had CTP core >50 cc and ASPECTS ≥6 (29% had modified Rankin scale 0–2, whereas 21% were deceased at 90 days). Moderate correlations between ASPECTS and final infarct volume (R=−0.42; P<0.01) and between CTP ischemic core and final infarct volume (R=0.50; P<0.01) were observed; coefficients were not significantly influenced by the time from stroke onset to presentation. Multivariable regression indicated ASPECTS ≥6 (odds ratio 4.10; 95% confidence interval, 1.47–11.46; P=0.01) and CTP core ⩽50 cc (odds ratio 3.86; 95% confidence interval, 1.22–12.15; P=0.02) independently and comparably predictive of good outcome. Conclusions— There is wide variability of CTP-derived core volumes within ASPECTS strata. Patient selection may be affected by the imaging selection method.

Carotid cavernous fistula after Pipeline placement: a single-center experience and review of the literature

Objective Carotid cavernous fistula (CCF) development after Pipeline Embolization Device (PED) treatment of cavernous carotid aneurysms (CCA) can be a challenging pathology to treat for the neurointerventionalist. Methods A database of all patients whose aneurysms were treated with the PED since its approval by the Food and Drug Administration in 2011 was retrospectively reviewed. Demographic information, aneurysm characteristics, treatment technique, antiplatelet regimen, and follow-up data were collected. A literature review of all papers that describe PED treatment of CCA was then completed. Results A total of 44 patients with 45 CCAs were identified (38 women, 6 men). The mean age was 59.9±9.0 years. The mean maximal aneurysm diameter was 15.9±6.9 mm (mean neck 7.1±3.6 mm). A single PED was deployed in 32 patients, with two PEDs deployed in 10 patients and three PEDs in 3 patients. Adjunctive coiling was performed in 3 patients. Mean follow-up duration based on final imaging (MR angiography or digital subtraction angiography) was 14.1±12.2 months. Five patients (11.4%) developed CCFs in the post-procedural period after PED treatment, all within 2 weeks of device placement. These CCFs were treated with a balloon test occlusion followed by parent artery sacrifice. Our literature review yielded only three reports of CCFs after PED placement, with the largest series having a CCF rate of 2.3%. Conclusions CCF formation is a known risk of PED treatment of CCA. Although transvenous embolization can be used for treating CCFs, parent artery sacrifice remains a viable option on the basis of these data. Studies support the view that adjunctive coiling may have a protective effect against post-PED CCF formation. None of the coiled aneurysms in our database or in the literature have ruptured. Follow-up data will lead to a better understanding of the safety profile of the PED for CCA.

Stroke etiology and collaterals: atheroembolic strokes have greater collateral recruitment than cardioembolic strokes

Chronic hypoperfusion from athero‐stenotic lesions is thought to lead to better collateral recruitment compared to cardioembolic strokes. It was sought to compare collateral flow in stroke patients with atrial fibrillation (AF) versus stroke patients with cervical atherosclerotic steno‐occlusive disease (CASOD).