Roberta Santos

Thrombectomy 24 hours after stroke: beyond DAWN

Background and purpose The results of the DAWN trial support the benefit of thrombectomy in patients with anterior circulation large vessel occlusion (LVO) acute stroke presenting within 6–24u2009hours from time last known well (TLKW). We sought to evaluate the characteristics and outcomes of patients who met DAWN criteria but underwent thrombectomy beyond 24u2009hours of TLKW. Methods A retrospective review of endovascular thrombectomy databases at three comprehensive stroke centers was performed to identify all patients who received thrombectomy beyond 24u2009hours of TLKW and otherwise met the DAWN criteria. Baseline characteristics, efficacy, and safety outcomes were compared with patients in the DAWN trial intervention arm. Results Twenty-one patients met the inclusion criteria. Rates of successful reperfusion (mTICI2b–3: 81% vs 84%, P=0.72), 90-day functional independence (modified Rankin Scale score 0–2, 43% vs 48%, P=0.68), and symptomatic intracranial hemorrhage (5% vs 6%, P=0.87) were comparable across the two groups. Conclusion Thrombectomy appears to be safe and feasible in patients with acute ischemic stroke due to LVO meeting all DAWN trial criteria but treated beyond 24u2009hours of TLKW with outcomes comparable to patients in the DAWN trial intervention arm. Further studies are warranted to validate these findings.

Reversible Cerebral Vasoconstriction Syndrome as an Unusual Complication of a Dural Arteriovenous Fistula treated with Onyx Embolization

BACKGROUNDnReversible cerebral vasoconstriction syndrome (RCVS) is a rare entity with an unknown pathophysiology. RCVS has been reported to occur more frequently in women age 20-50 years. Several causative mechanisms have been postulated involving transient deregulation of cerebral arterial tone, small vessel endothelial dysfunction, biochemical factors, hormonal deregulation, oxidative stress, and genetic predisposition. All these mechanisms and triggers are related to sympathetic overactivation, which eventually produces vasoconstriction. RCVS is distinguished by acute severe recurrent thunderclap headaches with or without other neurologic symptoms. However, the diagnosis can be challenging, requiring a high level of suspicion by the clinician, and RCVS is often underdiagnosed.nnnCASE DESCRIPTIONnWe present an unusual case of an 18-year-old female who developed RCVS after embolization of a dural arteriovenous fistula with onyx embolic material. Cerebral angiography was performed and verapamil was administered intra-arterially, resulting in a slight decrease in vasoconstriction with clinical improvement. The patient was maintained on oral verapamil during hospitalization. At a 7-month follow-up, the patient was neurologically stable, and cerebral angiography demonstrated no signs of vasoconstriction.nnnCONCLUSIONSnEndovascular procedures are a rare trigger for the development of RCVS and may be misdiagnosed. Prompt recognition of symptoms and diagnosis with treatment are necessary to reduce the risk of stroke. The management approach should be based on the premise of discontinuing precipitating drugs and administering calcium channel blocking agents.

PED Flex with Shield Technology: a feasible alternative for fusiform MCA aneurysms

The advent of flow diverters (FDs) has changed the scope of endovascular treatment options for intracranial aneurysms (IAs). FDs can effectively treat complex aneurysms in which both microsurgical and conventional endovascular options are less than ideal.1 2 The Pipeline Flexxa0Embolization Device (PED; Medtronic, Irvine, California,xa0USA) has been available in the USA for several years demonstrating positive results. More recently, the PED Flex with enhanced delivery features has been introduced, and although decreased, thromboembolic complications are still a potential risk.3 In light of this, a new surface modification was applied to the PED Flex known as Shield Technology consisting of a phosphorylcholine layer covalently bound to its metal braids potentially reducing its thrombogenicity.4 Herein, we report our initial experience using the PED Flex with Shield Technology in the treatment of an unruptured fusiform aneurysm located in the middle cerebral artery (MCA) using dual-antiplateletxa0therapy.nnA 32-year-old woman with history of sudden onset of headache and no other major relevant medical history presented for medical evaluation. Initial head CT and MRI showed no evidence of any haemorrhage, but MRI depicted a possible left MCA aneurysm. A CT angiography (CTA) revealed an unruptured fusiform aneurysm involving the inferior division of the left MCA. Treatment options consisting of observation, clip-wrapping, bypassxa0 or possible off-label use of PED were discussed with the patient. Decision was made to perform a cerebral angiogram and a three-dimensional reconstruction, with final therapeutic decision to be made based on bifurcation involvement. If both the superior and inferior divisions were involved, the treatment plan would consist of clip-wrapping but, if only the inferior division was diseased, then the plan was to use the PED. Cerebral angiogram demonstrated the complex morphology of the lesion exclusively compromising the inferior division of the MCA with two components measuring 3.9u2009mm × 3.0u2009mm and …

Specifics of Treatment for Basilar Trunk Artery Aneurysms

Abstract The estimated prevalence of intracranial aneurysms (IAs) in the general population ranges between 2% and 4% based on the radiographic and autopsy studies. The aneurysms of the posterior circulation account for 15% of all IAs and have a higher risk of rupture compared with those located in the anterior circulation. The basilar trunk artery is the segment in between the vertebrobasilar junction up to the superior cerebellar artery and the aneurysms located in this segment are extremely rare, constituting less than 1% of all IAs. In this chapter, we discuss their anatomical features and explore the pathophysiological mechanisms contributing to these lesions. Current evidence regarding surgical and endovascular interventions are examined. Although there is no consensus regarding the optimal treatment for lesions at the basilar trunk, decision is made on a case-by-case basis with extrapolation and assumptions based on results from the treatment for other cerebral aneurysms.

Three-dimensional printing and neuroendovascular simulation for the treatment of a pediatric intracranial aneurysm: case report

The use of simulators has been described in a variety of fields as a training tool to gain technical skills through repeating and rehearsing procedures in a safe environment. In cerebrovascular surgery, simulation of skull base approaches has been used for decades. The use of simulation in neurointervention to acquire and enhance skills before treating a patient is a newer concept, but its utilization has been limited due to the lack of good models and deficient haptics. The advent of 3D printing technology and the development of new training models has changed this landscape. The prevalence of aneurysms in the pediatric population is much lower than in adults, and concepts and tools sometimes have to be adapted from one population to another. Neuroendovascular rehearsal is a valid strategy for the treatment of complex aneurysms, especially for the pediatric population. The authors present the case of an 8-year-old boy with a fusiform intracranial aneurysm and documented progressive growth, who was successfully treated after the authors rehearsed the placement of a flow diverter using a patient-specific 3D-printed replicator system model.

Revisiting the therapeutic time window dogma: successful thrombectomy 6 days after stroke onset

Stroke is the leading cause of serious long-term disability in the USA. Recent clinical trials, DAWN and DEFUSE 3, have expanded the endovascular therapeutic time window which has been adopted by the American Heart Association stroke guideline. However, there continues to be a dilemma as to what is the best approach for patients who present beyond the time window set by these trials and the current guideline. The interval from arterial occlusion to completion of brain tissue infarction varies from patient to patient and depends on the actual time and also a physiological clock or a tissue time window. Offering endovascular treatment based solely on a rigid time criterion excludes patients who may have a clinical benefit because of potentially salvageable tissue. We present a case of a patient who underwent successful stroke thrombectomy 6 days after stroke onset.

De Novo Arteriovenous Malformation in a Pediatric Patient: Case Report and Review of the Literature

BACKGROUNDnAn arteriovenous malformation (AVM) consists of a pathologic arteriovenous shunt formed from a tangle of vessels lacking a capillary bed. AVMs were previously accepted as congenital in nature; however, an increase in the number of reported de novo cerebral AVMs challenges the assertion that all AVMs develop in utero hence, the possibility of these lesions presenting postnatally cannot be excluded. A review of literature revealed 31 published cases of de novo AVM formation between 1996 andxa02017.nnnCASE DESCRIPTIONnWe present the case of a 7-year-old boy with a history of an intracranial aneurysm that was found to have an asymptomatic de novo AVM formation on a routine follow-up angiography. He was being followed since the age of 8 months when the aneurysm was incidentally found during work-up for mild hemiparesis. At that time, magnetic resonance imaging revealed a 4-mm right posterior communicating artery aneurysm along with a right hemispheric stroke and cortical dysplasia. No arteriovenous malformation was noted.nnnCONCLUSIONSnThe exact pathophysiology of de novo AVMs is not completely understood, but a combination of genetic, molecular, and environmental factors may play a role. Our case report only adds to the growing body of clinical evidence supporting the notion that these lesions may be acquired. It would be appropriate to consider an AVM as an abnormal vascular response to an injury rather than a static congenital lesion.

Referral facility CT perfusion prior to inter-facility transfer in patients undergoing mechanical thrombectomy

Background and purpose The use of CT perfusion (CTP) imaging at a referring hospital is feasible and may shorten the door to puncture time for patients with acute ischemic stroke. Methods We conducted a single center retrospective review of a prospectively maintained database of consecutive ischemic stroke patients transferred to our center for consideration of endovascular therapy. Patients were divided into two groups. Group 1 consisted of patients transferred from facilities where CTP (using automated RAPID software) was routinely performed and group 2 consisted of patients transferred from facilities that did not perform perfusion imaging. Results We identified a total of 132 patients, all of whom were transferred to our center, from April 2014 to April 2017. There were no differences in baseline characteristics between the two groups. A total of 34 patients were transferred from a facility after CTP (group 1) and 98 were transferred from a facility with no CTP (group 2). Door to puncture time was significantly shorter for patients in group 1 compared with those in group 2 (median 12 (IQR 8–16) min and 48.5 (32.8–71.8)u2009min, respectively; P<0.001). Despite obtaining additional pre-transfer imaging in group 1, there was no difference in door in and door out times at the referring facilities compared with group 2. Conclusions We found that triaging from a primary stroke center after CTP RAPID was feasible and significantly reduced the door to puncture time without any significant delay in the transfer process.

Rare arch and supra-aortic vessel anomaly

A 3-year-old child with history of a large secundum atrial septal defect came to our institution for surgical cardiovascular evaluation. The patient had reached all developmental milestones and was completely asymptomatic. During imaging workup, a three-dimensional magnetic resonance angiographyxa0(MRA) reconstruction showed an incidental finding of a unique left aortic arch with branch vessel anomalies. The images showed a fenestrated origin of the left common carotid artery (figure 1A) along with an independent origin of the right internal and external carotid arteries from the brachiocephalic trunk, with a partial …