Timothy Hampton

Mural destabilization after aneurysm treatment with a flow-diverting device: a report of two cases

Background Flow-diverting stents have demonstrated great promise for the treatment of cerebral aneurysms; however, clinical experience with the devices remains very preliminary. We present two cases of spontaneous delayed complications—one fatal aneurysm rupture and one symptomatic increase in aneurysm volume—following the treatment of intradural aneurysms with the Pipeline Embolization Device (PED). Presentation/intervention Two patients with unruptured, intradural aneurysms of the carotid artery underwent uneventful treatment with the PED (eV3, Irvine, California, USA). One patient, with a giant aneurysm of the carotid terminus, experienced worsening headache 5 days after the procedure and ultimately collapsed and became unresponsive. CT of the head demonstrated acute subarachnoid and intraventricular hemorrhage. The patient died the following day. A second patient with a large left posterior communicating artery aneurysm presented with progressive memory loss 3 months after PED reconstruction of the carotid artery. Although serial CT angiograms showed progressive thrombosis of the aneurysm to near-complete occlusion, MR of the brain demonstrated marked interval growth of the collective aneurysm–intra-aneurysmal thrombus mass with extensive edema throughout the adjacent left temporal lobe. Conclusions Flow-diverting devices have demonstrated tremendous promise for the treatment of complex, unruptured cerebral aneurysms. However, experience with this novel approach to aneurysm treatment is preliminary and the consequences of its application within the cerebrovasculature remain incompletely defined. Mural destabilization resulting in delayed, spontaneous, aneurysm growth and/or rupture may occur in the days to weeks following the application of flow-diverting devices to treat previously unruptured intracranial aneurysms. A better understanding of the incidence and etiology of these complications is essential for this technology to be optimally applied.

The application of near-infrared oximetry to cerebral monitoring during aneurysm embolization: a comparison with intraprocedural angiography.

Near-infrared spectroscopy (NIRS) has been used to monitor regional cerebral oxygen saturation (rSO2) in patients at risk of cerebral desaturation during surgical and neurointerventional procedures. However, the quantitative capabilities of the method have been questioned, as has its validation compared with jugular bulb oximetry. Here, we compare NIRS data acquired during coil embolization procedures with incidence of vasospasm as detected from angiography. Thirty-two subarachnoid hemorrhage patients underwent embolization. Bilateral SomaSensor strips (Invos 4100, Somanetics) were affixed to the forehead at constant anatomic positions, avoiding frontal sinuses and scalp hair. Mean arterial pressure, SaO2, end-tidal pCO2, temperature and Hb were held within a narrow range during the procedure. Ipsilateral angiography was performed every 10 to 15 minutes. An independent neuroradiologist classified any vasospasm in the parent vessel as mild (25% baseline), moderate (50%), severe (75%), or total (100%). Of all, 15/32 (46.9%) patients developed spasm; in 2 it was severe or total. There was no significant association between World Federation of Neurological Surgeons grade and baseline rSO2 signal (either ipsilateral or contralateral to the side of the aneurysm) (P=0.598). There was no significant association between side of aneurysm and baseline rSO2 signal (P=0.243). However, episodes of angiographic spasm were strongly associated with reduction in trend ipsilateral NIRS signal (P<0.001); furthermore, the degree of spasm (especially more than 75% vessel diameter reduction) was associated with a greater reduction in same-side NIRS signal (P<0.001) (2-level random effects regression model, Stata 8.2, Stata Corp, TX). NIRS may have a useful role to play in the detection of cerebral desaturation secondary to vasospasm during neuroendovascular procedures.

Nontraumatic extradural hematoma in sickle cell anemia: A rare neurological complication not to be missed†

A 20-year-old black African-Caribbean male (patient 1), known to have sickle cell anemia (SCA) and on hydroxyurea therapy, presented to our hospital with a one day history of chest and lower back pain. He had a history of multiple previous vaso-occlusive crises requiring simple analgesia. At the time of admission, he was afebrile and hemodynamically stable with no abnormalities detected on physical examination. Laboratory values on admission were: hemoglobin (Hb) 117 g/L (usual baseline Hb 110 g/L), hematocrit 37%, white cell count 14.0 3 10/L, reticulocyte count 216 3 10/L, platelets 303 3 10/L, serum creatinine 49 mmol/L, and total serum bilirubin 75 mmol/L. Sickle cell disease (SCD) results from the recessive inheritance of a mutant beta globin gene in which valine is substituted for glutamic acid at position 6 of the beta-globin chain, resulting in the formation of sickle hemoglobin (HbS). Our patient had sickle cell anemia (SCA), the homozygous form (HbSS) and presented with symptoms suggestive of vaso-occlusion, a hallmark feature of SCD. Vaso-occlusion is caused by the deformed sickle shaped red cells blocking microvasculature leading to tissue infarction and acute inflammation, which results in a painful “crisis” for the patient. At this stage, it appeared that our patient was suffering from a simple unprecipitated vaso-occlusive crisis. Patient 1 was commenced on supportive therapy with simple analgesia, oral fluids, and low molecular weight heparin (LMWH) for prevention of venous thromboembolism. The next day he spiked a fever and was started on intravenous antibiotics because of consolidation on the chest X-ray, consistent with acute chest syndrome. On the same day, he reported a lump on his head over the left parietal area, which was fluctuant and initially measured 2 3 4 cm. The patient denied any headache or trauma. Over the next 24 hr, he deteriorated with ongoing fevers and worsening pain requiring escalation to an opiate based “patient controlled analgesia” pain relief. His laboratory parameters also changed significantly: Hb dropped acutely to 54 g/L with a hematocrit of 17%, and reticulocyte count of 69.9 3 10/L; his platelet count dropped to 75 3 10/L with normal coagulation (PT, APTT, fibrinogen). His C-reactive protein (CRP) level reached a peak of 408 mg/L. The hemolysis markers became markedly elevated: lactate dehydrogenase (LDH) reaching a peak of 3,675 IU/L and bilirubin 200 mmol/L (conjugated bilirubin 29 mmol/L). Three units of packed red blood cells were transfused improving his Hb to 84 g/L. The LMWH was stopped in view of the thrombocytopenia. Twelve hours after the acute fall in Hb, it was noted that his scalp lump had increased in size to 6 3 8 cm and the patient then complained of paraesthesia involving the left side of his chin together with a mild frontal headache. Another hallmark feature of SCD is the hemolytic anemia due to the shortened life-span of the irreversibly sickled RBCs. Patient 1’s findings were consistent with an acute hemolytic episode but the massively elevated LDH combined with an acute drop in the platelet count, were findings not commonly encountered in typical vaso-occlusive crises, where the increase in hemolysis is mild to moderate and mild thrombocytosis, more typical. The drop in platelet count raised the possibility of thrombotic thrombocytopenic purpura but the ADAMTS13 level was normal at 80% (normal range 60–123%). Post transfusion, his Hb remained stable with HbS between 45 and 47%, and his hemolytic parameters improved, reticulocytes returned to baseline at 167 3 10/L. His respiratory problems slowly improved during the admission. The rapidly increasing scalp lump was investigated with an ultrasound scan which demonstrated a hematoma and this unusual finding combined with the facial paraesthesia prompted intracranial imaging. Some of the most devastating complications of sickle cell disease involve the cerebrovascular system. Cerebral lesions of ischemic origin account for up to 75% of the neurological manifestations, the remaining 25% are hemorrhagic, mainly intracerebral and subarachnoid hematomas [1]. There are very few case reports describing the occurrence of spontaneous (nontraumatic) extradural hematomas as a complication of sickle cell disease. Patient 1 underwent an urgent head computed tomography (CT) scan followed by a magnetic resonance imaging (MRI), which demonstrated: (1) an 11 mm deep extradural hematoma overlying the left frontal lobe (see Fig. 1A,B) with deformation of the subjacent brain but without midline shift; (2) the scalp lesion to be a subgaleal hematoma overlying the left frontal and parietal bones; (3) signal changes in the parietal bone (high T1 and T2, with associated increased diffusion weighted signal) considered to represent bone infarction; and (4) further bone infarction within the left mandibular marrow with a hematoma adjacent to the left condylar/subcondylar region and sigmoid notch which was thought to account for the chin paraesthesia. Throughout his inpatient stay, he remained fully conscious (Glasgow Coma Score, GCS, of 15), alert and

Prevalence of recurrence and retreatment of ruptured intracranial aneurysms treated with endovascular coil occlusion

Abstract Object. Endovascular coiling is a common treatment for ruptured intracranial aneurysms. However, concerns have been raised over the durability of this treatment. The aim of this study was to establish the rate of recurrence and retreatment of coiled aneurysms treated in our unit. Methods. We performed a retrospective analysis of 264 surviving patients with ruptured aneurysms treated by endovascular coiling between November 2003 and April 2007. Data was collected on patient age, location of aneurysm, angiogram results and any subsequent retreatment. Results. Follow-up angiography performed at 6 months was available in 239 cases (91%) and revealed 158 (66%) aneurysms completely occluded, 51 (21%) had neck recurrence and 31 (13%) had significant recurrence. Thirty (12.6%) aneurysms required retreatment over a mean follow-up period of 46 (range 24–66) months. Younger age predisposed to a higher risk of recurrence and retreatment. Aneurysms of the anterior communicating and anterior cerebral arteries were less likely to recur or require retreatment (relative risk 0.42 and 0.29, respectively); aneurysms of the posterior communicating arteries were more likely to recur (relative risk 2.22). Aneurysms of the basilar and carotid arteries were more likely to undergo retreatment (relative risk 2.84 and 2.46, respectively). Conclusion. Long-term follow-up is required for ruptured aneurysms treated by coiling. Certain subgroups may require closer follow-up due to the increased risk of recurrence or retreatment, such as younger patients and those with aneurysms of the posterior communicating, basilar or carotid arteries.

Fatal granulomatous amoebic meningoencephalitis due to Balamuthia mandrillaris.

Amoebic infections of the central nervous system (CNS) are very rare and usually fatal. A 33-year-old Bolivian male injured his elbow 18 months ago in an accident and, months later, developed multiple skin lesions. He was admitted with confusion, and brain images showed large multifocal lesions with mass effect. Review of the skin biopsy revealed the presence of amoebic trophozoites within a granulomatous inflammation. Despite treatment, he continued to deteriorate and died 17 days after admission. The brain was swollen with prominent uncal herniation, and the leptomeninges showed patchy exudate. Coronal sections revealed widespread hemorrhagic and necrotic lesions. Histology confirmed granulomatous amoebic meningoencephalitis (GAM) with the presence of amoebic trophozoites and occasional cysts. Post-mortem culture confirmed Balamuthia mandrillaris. GAM due to B. mandrillaris may occur in any age group, may or may not be associated with immunosuppression, and is present worldwide. It usually has a subacute and fatal course from hematogenous dissemination of chronic skin or lung lesions.

Outcome study of the pipeline embolization device for treatment of intracranial aneurysms at a single UK institution

Abstract Background: The introduction of flow-diverting stents in the last decade provides an alternative endovascular treatment choice in selected intracranial aneurysms. This retrospective analysis of a UK centre’s experience provides insight into clinical and radiographic outcomes. Methods: Electronic patient records, diagnostic and procedural images and written procedural records for patients treated with the PED between August 2009 and April 2014 were reviewed. Follow-up TOF MRA was performed after treatment. Clinical and radiographic outcomes were analyzed and compared with other PED studies. Results: Twenty-nine patients with 30 attempted PED treatments were reviewed representing 3.5% of the treated aneurysm patient cohort. 63.6% (21/33) of the aneurysms were wide-necked (>4 mm), 60.6% (20/33) were large or giant (≥10 mm). The mean aneurysm sac diameter was 12.0 mm; the mean neck width was 4.5 mm. Mortality and morbidity rates were 3.3% and 10.0%, respectively. The total adequate occlusion rate was 78.1% (25/32) at 18 months. The neck width of aneurysms with residual sac filling and complete occlusion differed significantly (p = 0.04). Conclusions: Highly selected aneurysms treated with a PED in a UK centre have similar occlusion and complication rates when compared to non-UK studies. Again, it appeared that delayed aneurysm rupture remained a risk for PED treatment in large or giant aneurysms. Follow-up with TOF MRA gave similar occlusion results compared to those obtained with DSA in other studies. The influence of neck size on occlusion rate should be examined in future PED studies.

“Brain on fire”: A new imaging sign

Primary central nervous system (CNS) marginal zone B cell lymphoma is a rare condition. It has an indolent disease course and usually presents as a dural-based lesion. We present a patient with non-dural-based, primary CNS marginal zone B cell lymphoma with an unusual imaging appearance, not previously described to our knowledge.

Extracranial displacement of a ventricular catheter following trauma

We report a case of complete extracranial displacement of the proximal part of a ventriculo-peritoneal shunt following trauma. The possible mechanism of the delayed displacement of the shunt is discussed. The importance of early recognition of this unusual cause of shunt dysfunction is considered.

Rare case of bilateral traumatic internal carotid artery dissection

A 55-year-old man was working in a trench when the wall collapsed in on him, pinning him to the wall. On arrival in the emergency department the patient began reporting of right-sided headache. Neurological examination revealed left-sided reduced sensation with weakness. Whole-body CT scan showed right-sided flail chest and bilateral haemothorax as well as loss of flow and thinning of the distal right internal carotid artery (ICA) and loss of grey white matter differentiation in keeping with traumatic ICA dissection with a right middle cerebral artery (MCA) infarct. He was started on aspirin 300 mg once daily. 3 days postadmission the patient experienced worsening of vision and expressive dysphasia. CT angiogram showed bilateral ICA dissections extending from C2 to the skull base. The patient was managed conservatively in the stroke unit for infarction and was discharged home for follow-up in stroke clinic.