M Soltanolkotabi

Onyx embolization of intracranial arteriovenous malformations in pediatric patients.

OBJECT The authors undertook this study to assess the safety and efficacy of Onyx embolization in the treatment of intracranial arteriovenous malformations (AVMs) in pediatric patients. METHODS All pediatric Onyx embolization of intracranial AVM cases performed consecutively at a single childrens hospital over a 5-year period were collected and evaluated. RESULTS Twenty-five patients (mean age 10.5 years) underwent a total of 38 procedures. An aggregate of 56 pedicles were embolized (mean 1.47 per session). The Spetzler-Martin grade was determined in all cases. Onyx embolization resulted in complete obliteration of the AVM in 3 cases (12%) and partial obliteration in 22 cases (88%). A total of 23 patients underwent surgical treatment. The mean preoperative AVM devascularization in these cases was 72%. One patient was treated with radiosurgery following Onyx embolization. Overall, 10 complications occurred in a total of 38 procedures (26.3%). None of the complications resulted in permanent neurological morbidity. The rate of transient neurological complications was 10.5% (4 of 38 procedures) and the rate of transient nonneurological complications was 5.3% (2 of 38 procedures). The remaining 4 complications were clinically silent (rate of 10.5%). There were no procedure-related deaths in this study population. There was no significant difference in patients with and without complications in terms of demographic characteristics, AVM grade, or embolization features (p ≥ 0.2). Deep venous drainage was associated with higher complication rates (p = 0.03). CONCLUSIONS Onyx utilization is feasible for preoperative or primary embolization in the treatment of pediatric intracranial AVMs; however, the spectrum of complications encountered is broad, and attention must be paid to the technical nuances of and indications for its use to avoid many potential dangerous effects. Although the overall complication rates were higher than expected, all were either clinically silent or had only transient clinical effects. Thus, this experience suggests that Onyx embolization can be performed safely with a low rate of permanent morbidity in pediatric patients harboring these difficult lesions.

Perfusion-based selection for endovascular reperfusion therapy in anterior circulation acute ischemic stroke

The authors attempted to determine if reperfusion therapy for anterior circulation acute stroke based on MR perfusion resulted in better outcomes at 3 months than that based on noncontrast CT. Perfusion imaging-selected patients had a better outcome than those selected with only noncontrast CT but MR perfusion- and CT perfusion-selected patients had similar outcomes. In this multicenter study, patients with acute stroke who underwent perfusion imaging were more than 2-fold more likely to have good outcomes following endovascular reperfusion therapy BACKGROUND AND PURPOSE: Controversy exists about the role of perfusion imaging in patient selection for endovascular reperfusion therapy in acute ischemic stroke. We hypothesized that perfusion imaging versus noncontrast CT- based selection would be associated with improved functional outcomes at 3 months. MATERIALS AND METHODS: We reviewed consecutive patients with anterior circulation strokes treated with endovascular reperfusion therapy within 8 hours and with baseline NIHSS score of ≥8. Baseline clinical data, selection mode (perfusion versus NCCT), angiographic data, complications, and modified Rankin Scale score at 3 months were collected. Using multivariable logistic regression, we assessed whether the mode of selection for endovascular reperfusion therapy (perfusion-based versus NCCT-based) was independently associated with good outcome. RESULTS: Two-hundred fourteen patients (mean age, 67.2 years; median NIHSS score, 18; MCA occlusion 74% and ICA occlusion 26%) were included. Perfusion imaging was used in 76 (35.5%) patients (39 CT and 37 MR imaging). Perfusion imaging–selected patients were more likely to have good outcomes compared with NCCT-selected patients (55.3 versus 33.3%, P = .002); perfusion selection by CT was associated with similar outcomes as that by MR imaging (CTP, 56.; MR perfusion, 54.1%; P = .836). In multivariable analysis, CT or MR perfusion imaging selection remained strongly associated with good outcome (adjusted OR, 2.34; 95% CI, 1.22–4.47), independent of baseline severity and reperfusion. CONCLUSIONS: In this multicenter study, patients with acute ischemic stroke who underwent perfusion imaging were more than 2-fold more likely to have good outcomes following endovascular reperfusion therapy. Randomized studies should compare perfusion imaging with NCCT imaging for patient selection for endovascular reperfusion therapy.

Ruptured Spinal Artery Aneurysm Associated with Coarctation of the Aorta

BACKGROUND Spinal artery aneurysms associated with aortic coarctation are exceptionally rare, with only eight cases reported in the literature that we are aware of, and treatment of the aneurysm described only in one of them. Aortic coarctation often results in an aberrant collateral circulation with hyperdynamic flow and potential spinal artery aneurysm formation, growth, and rupture. Microsurgical, interventional, and medical management of these lesions can be challenging and has rarely been reported. Complication avoidance requires thorough knowledge of the clinical presentation of the disease, the hemodynamic factors involved, and the therapeutic tools available. CASE DESCRIPTION A 59-year-old woman with a previously undiagnosed isthmic coarctation of the aorta presented with subarachnoid hemorrhage. A 7-mm wide-necked, saccular spinal artery aneurysm was identified as the source of the hemorrhage and was subsequently successfully coiled through a transbrachial access route. After rehabilitation, the patient returned to her asymptomatic neurologic baseline, and underwent successful surgical repair of the aortic coarctation with placement of an interposition graft. CONCLUSIONS Spinal artery aneurysms induced by aortic coarctation are rare and complex entities. They pose unique surgical and medical challenges. Securing the aneurysm should be prioritized specifically in cases of subarachnoid hemorrhage. Blood pressure should be closely monitored and balanced to reduce the risk of rehemorrhage and at the same time allow for sufficient end-organ perfusion.

Spontaneous post-partum cervical carotid artery dissection in a patient with reversible cerebral vasoconstriction syndrome.

Post-partum cervicocephalic artery dissection (pp-CAD) is a rare and poorly understood condition. To our knowledge, only 21 cases have been reported. Reversible cerebral segmental vasoconstriction (RCSV) was first described by Call and Fleming in 1988, and its association with pp-CAD has only been reported in three cases. However, in those cases it is unclear whether the pp-CAD may have been caused by straining during labor and therefore merely coincidental to the intracranial arteriopathy. We describe a 41-year-old right-handed African-American woman who developed the syndrome of pp-CAD (headaches, trace subarachnoid hemorrhage and diffuse cerebral arteriopathy on angiogram) two weeks after delivery. In this unique case, the patient had fortuitously undergone an MR study twice over a four day period which included the carotid bifurcations. During that time the patient was an inpatient, on bed rest and subject to continuous cardiac monitoring. The interval studies documented a true spontaneous right internal carotid artery dissection occurring without obvious cause. The patient had noted moderate right neck pain developing between the two MR studies but experienced no neurological deficits. Subsequent conventional angiography confirmed the presence of postpartum cerebral arteriopathy and the cervical dissection. The patient was managed conservatively with antiplatelet medication and had an otherwise uneventful course. We hypothesize whether transient arterial wall abnormalities, postpartum hormonal changes or subtle connective tissue aberrations play a similar role in the pathogenesis of these two associated conditions.

Endovascular Management of Pediatric High-Flow Vertebro-Vertebral Fistula with Reversed Basilar Artery Flow: A Case Report and Review of the Literature

Vertebral artery arteriovenous fistula (VAVF) is mostly known as a post-traumatic and/or iatrogenic arteriovenous complication. However, spontaneous high-flow VAVF associated with flow reversal in the basilar artery has not been reported in children. We describe a unique asymptomatic presentation of a spontaneous high-flow VAVF associated with flow reversal in the basilar artery in a pediatric patient. The literature for classification, pathophysiology, treatment strategies, and post-procedural complications is also reviewed.

Juvenile Pilocytic Astrocytoma in Association with Arteriovenous Malformation

Pilocytic astrocytomas are highly vascular, relatively common primary brain tumors in the pediatric population, but their association with a true arteriovenous malformation (AVM) is extremely rare. We describe an eight-year-old girl with a right supratentorial juvenile pilocytic astrocytoma (WHO grade I) with an angiographically documented AVM entangled in the tumor mass who presented with intracranial hemorrhage due to a ruptured anterior choroidal artery pseudoaneurysm encased in the lesion. The AVM nidus as well as the hemorrhage site was embolized with Onyx. A literature review revealed only one previous report of a true intermixture of these two lesions. We hypothesize whether the association of vascular malformations and primary brain tumors are merely coincidental or if they point to the existence of a distinct entity and/or a common etiologic factor.

Endovascular correction of an infantile intracranial venous outflow obstruction

The authors report on the case of a 7-year-old boy who presented with a reduced level of activity, macrocephaly, prominent scalp veins, and decreased left-sided visual acuity. Imaging workup demonstrated generalized cerebral volume loss, bilateral chronic subdural hematomas, absent left sigmoid sinus, hypoplastic left transverse sinus, and severe focal weblike stenosis of the right sigmoid sinus. Right sigmoid sinus angioplasty and stent insertion was performed, with an immediate reduction in the transduced intracranial venous pressure gradient across the stenosis (from 22 to 3 mm Hg). Postprocedural diminution of prominent scalp and forehead veins and spinal venous collateral vessels was followed by a progressive improvement in visual acuity and physical activity over a 1-year follow-up period, supporting the efficacy of angioplasty and stent insertion in intracranial venous outflow obstruction. There are multiple potential causes of intracranial venous hypertension in children. Development of dural sinus stenosis in infancy may be one such cause, mimicking the clinical presentation of other causes such as vein of Galen malformations. This condition can be ameliorated by early endovascular revascularization.

Neuroimaging in acute stroke: Choosing the right patient for neurointervention

Although the non-contrast computed tomography head continues as the sole mandatory imaging technique before intravenous thrombolysis, the increased availability of advanced infarct/penumbral imaging techniques and confidence in their use have led many to adopt them into routine practice--most particularly before intra-arterial interventions. Computed tomography versus magnetic resonance-based routes to imaging the cerebral vasculature, cell death, and parenchymal perfusion have differing advantages in terms of speed, availability, exposures to contrast and radiation, sensitivity, and resolution. Continued refinement and future developments, such as the ability to quantitate perfusion, promise to lead to tailored treatment protocols that respect the individual variations in anatomy, physiology, and pathology. This should lead both to an extension of treatment to patients currently excluded by rigid time windows and the avoidance of futile therapies and their associated morbidities.

E-005 Short-term Outcomes of Acute Ischemic Stroke Patients with MCA/ICA Occlusion Excluded for Intra-arterial Reperfusion Therapy

Introduction Large-vessel occlusions account for 45% of patients with acute ischemic stroke (AIS) presenting to the emergency departments in the United States. Many of these patients may not be eligible candidates for intravenous tPA therapy; however, they may benefit from receiving intra-arterial therapy (IAT). Optimal patient selection plays a pivotal role in identification of those AIS patients who may benefit from IAT. However, no method has been introduced as the gold standard for patient selection among neurointerventionalists in the clinical practice. Therefore, many of the stroke patients with large vessel occlusion presenting in the acute setting do not receive IAT. We aimed to review the short-term outcome of AIS patients with large vessel occlusion who were not selected for IAT. Methods We retrospectively reviewed consecutive AIS patients with National Institute of Health Stroke Scale (NIHSS) score of more than 8 and CTA/MRA verified MCA/ICA occlusion who did not receive endovascular thrombectomy/thrombolysis treatment. Data were collected on demographics, initial NIHSS score, the cause for not being eligible for endovascular intervention, and mortality rate during the first 30 days. Eligibility for undergoing IA thrombectomy/thrombolysis treatment based on CT/MR perfusion imaging profiles was defined as CBV/DWI infarct core 20% infarct core. Results Thirty one AIS patients (19 F/12 M; mean age of 78.1(32–93; SD: ±13.44 years) were studied. Mean and median baseline NIHSS score were 20.06 (8–40; SD: ± 8.25) and 19, respectively. Mortality in the first 30 days was 38.7% (12/31) and 6 patients (20%) were referred to hospice. Among fourteen patients who did not undergo endovascular thrombectomy/thrombolysis reperfusion therapy due to the unfavorable perfusion profile, six patients expired and 4 patients were referred to the hospice, in the first 30 days. Seventeen patients were not intervened due to improvement in NIHSS score following receiving intravenous tPA, advanced age, severely high NIHSS score, and high risk clinical profile for intervention. Among these patients, six patients expired and two patients were referred to hospice. Conclusion In this cohort of patients, we observed relatively high mortality rate and poor short-term clinical outcomes in AIS patients with large vessel occlusion who were not selected for IAT. Patients excluded from receiving IAT using imaging-based methods, generally had worse outcomes compared with those patients who were selected based on clinical evaluation. Efforts should be made to develop a standard and accurate patient selection method for identification of the optimum number of AIS patients with large vessel occlusion who may benefit from IAT. Disclosures A. Honarmand: None. R. Beck: None. M. Soltanolkotabi: None. S. Ansari: None. A. Shaibani: None. V. Daruwalla: None. M. Hurley: None.

Use of Onyx for endovascular embolization of pediatric spinal perimedullary (Type IV) fistula: Case report

Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Neurointerventional Surgery, Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Neurointerventional Surgery, Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Division of Neurosurgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, IL, USA