Tufail Patankar

Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study

Summary Background Public objection to autopsy has led to a search for minimally invasive alternatives. Imaging has potential, but its accuracy is unknown. We aimed to identify the accuracy of post-mortem CT and MRI compared with full autopsy in a large series of adult deaths. Methods This study was undertaken at two UK centres in Manchester and Oxford between April, 2006, and November, 2008. We used whole-body CT and MRI followed by full autopsy to investigate a series of adult deaths that were reported to the coroner. CT and MRI scans were reported independently, each by two radiologists who were masked to the autopsy findings. All four radiologists then produced a consensus report based on both techniques, recorded their confidence in cause of death, and identified whether autopsy was needed. Findings We assessed 182 unselected cases. The major discrepancy rate between cause of death identified by radiology and autopsy was 32% (95% CI 26–40) for CT, 43% (36–50) for MRI, and 30% (24–37) for the consensus radiology report; 10% (3–17) lower for CT than for MRI. Radiologists indicated that autopsy was not needed in 62 (34%; 95% CI 28–41) of 182 cases for CT reports, 76 (42%; 35–49) of 182 cases for MRI reports, and 88 (48%; 41–56) of 182 cases for consensus reports. Of these cases, the major discrepancy rate compared with autopsy was 16% (95% CI 9–27), 21% (13–32), and 16% (10–25), respectively, which is significantly lower (p<0·0001) than for cases with no definite cause of death. The most common imaging errors in identification of cause of death were ischaemic heart disease (n=27), pulmonary embolism (11), pneumonia (13), and intra-abdominal lesions (16). Interpretation We found that, compared with traditional autopsy, CT was a more accurate imaging technique than MRI for providing a cause of death. The error rate when radiologists provided a confident cause of death was similar to that for clinical death certificates, and could therefore be acceptable for medicolegal purposes. However, common causes of sudden death are frequently missed on CT and MRI, and, unless these weaknesses are addressed, systematic errors in mortality statistics would result if imaging were to replace conventional autopsy. Funding Policy Research Programme, Department of Health, UK.

Experience of mechanical thrombectomy for paediatric arterial ischaemic stroke

BACKGROUND Paediatric arterial ischaemic stroke (AIS) is an important cause of acute neurological symptoms in children, it causes significant morbidity and is one of the top ten causes of childhood deaths. Consensus papers have suggested guidelines for the management of AIS in childhood, although none recommend thrombectomy. Despite this, children within our institution have undergone mechanical thrombectomy for large vessel occlusion. This is the first series of mechanical thrombectomy and outcomes performed in children in the U.K. METHODS We describe the endovascular management of paediatric arterial ischaemic stroke (AIS) in four children (5-15 years) with PedNIHSS > 17. RESULTS Three had basilar artery (BA) occlusion and one left middle cerebral artery (MCA) occlusion. All underwent uncomplicated thrombectomy followed by intravenous heparin. One had a successful second attempt. The BA cases underwent thrombectomy 17-36 h after symptom onset; the left MCA case <6 h after symptom onset. Modified Rankin Scale (MRS) was 0-3, 50% had MRS 0. DISCUSSION Adult AIS guidelines recommend IV recombinant tissue plasminogen activator (r-tPA) within 4.5 h of onset and intra-arterial r-tPA within 6 h; thrombectomy being reserved for carefully selected patients. Paediatric AIS recognition is problematic, often with delayed imaging. There is little evidence regarding efficacy of thrombectomy for paediatric AIS. Our experience suggests there may be a role for endovascular clot retrieval in selected patients managed by an experienced multidisciplinary team. Careful data collection is mandatory.

Endovascular treatment of cerebral aneurysms using the Woven EndoBridge technique in a single center: preliminary results

OBJECTIVE The Woven EndoBridge (WEB) is an innovative new technique for securing cerebral aneurysms. It is designed particularly for wide-necked bifurcation aneurysms that otherwise would be difficult to treat. There is a paucity of follow-up data in the literature due to the novelty of this technique. The authors reviewed their data from cases involving patients treated at Leeds General Infirmary with the WEB device. They assessed the safety and complication risk associated with the device and clinical and radiological follow-up outcomes in their patients. This is, to their knowledge, the first publication to include the new single-layer sphere device (WEB SLS) in addition to the original dual-layer (WEB DL) and the (nonsphere) single-layer (WEB SL) devices. METHODS Data from 22 patients who underwent 25 WEB treatments were analyzed. Of the 25 WEB procedures, 3 were performed on an acute basis, 1 was performed on a semiacute basis, and the remaining 21 were elective. A novel 6-point scoring system called the Leeds WEB aneurysm occlusion scale was created to ensure accurate assessment based on the morphology of the WEB device. Outcome was assessed at follow-up by MR angiography with or without digital subtraction angiography and the modified Rankin Scale (mRS). RESULTS Deployment of the WEB device was successful in 22 (88%) of 25 procedures; 3 (12%) of the attempts at WEB treatment were abandoned. One of the patients in whom treatment was abandoned underwent a successful second attempt. Immediately after the 22 procedures with successful deployment, 4 (18%) of the patients had a complete occlusion of the aneurysm and WEB device; 10 (45%) had varying degrees of occlusion within the WEB device but no aneurysm neck or remnant; 3 (14%) had a neck remnant; and 5 (23%) had an aneurysm remnant. Of the patients with an aneurysm remnant, 1 had a complete aneurysm occlusion at ≥ 3-months follow-up. In total, 6 (27%) patients had a residual aneurysm at ≥ 3-months radiological follow-up. One of these patients was admitted with hydrocephalus secondary to a recurrent aneurysm and later received a second WEB treatment with additional coiling. Only 1 patient developed new neurological symptoms. This patient went from an mRS score of 0 to a score of 1 and had radiological evidence of a thromboembolic event. Two patients showed radiological evidence of a new thromboembolic event on follow-up MRI but were clinically asymptomatic. CONCLUSIONS The WEB has shown itself to be a promising new device with the potential to increase the scope of treatment for difficult wide-necked bifurcation aneurysms. The technique is safe, and short-term results show effective occlusion of complex aneurysms with minimal complications associated with the procedure. Long-term efficacy, however, still needs to be assessed.

Emergent extracranial internal carotid artery stenting and mechanical thrombectomy in acute ischaemic stroke

Objective Tandem occlusions involving both the extracranial internal carotid artery (ICA) and an intracranial artery typically respond poorly to intravenous (IV) tissue plasminogen activator (t-PA). We retrospectively review our experience with proximal ICA stenting and stent-assisted thrombectomy of the distal artery. Methods The data included patients that underwent carotid stenting and mechanical thrombectomy between 2012–2013. Radiographic, clinical, and procedural data were drawn from case notes, imaging records and discharge reports. Clinical outcomes were evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale (mRs). Results Seven patients, with a mean age of 66.4 years and a mean admission NIHSS of 18.3, underwent this procedure and were included. Each presented with an occlusion of the proximal ICA, with additional occlusions of the ICA terminus (n = 3), middle cerebral artery (n = 5), or anterior cerebral artery (n = 1). Recanalisation of all identified occlusions was achieved in all patients, with a Thrombolysis in Myocardial Infarction (TIMI) score of 3 and a Thrombolysis in Cerebral Infarction (TICI) score >2b achieved in each case. Mean time from onset of stroke symptoms to recanalisation was 287 min; mean time from first angiography to recanalisation was 52 min. Intracranial haemorrhages occurred in two patients, with no increase in NIHSS. There were no mortalities. Mean NIHSS at discharge was 4.9, and mRs at 90 days was one in all patients. Conclusions Treatment of tandem extracranial ICA and intracranial occlusions in the setting of acute ischaemic stroke with extracranial carotid artery stenting followed by adjunctive intracranial mechanical thrombectomy is both safe and effective, but further evaluation of this treatment modality is necessary.

Initial experience of coiling cerebral aneurysms using the new Comaneci device

We present our initial patient experience with an innovative temporary bridging device, the Comaneci (Rapid Medical, Israel), to assist in the coiling of cerebral aneurysms. The Comaneci device confers the same benefits as balloon remodeling but without the risks of parent artery occlusion. This alleviates time pressure on the clinician, and could reduce the risk of parent artery thrombosis. Three patients were treated with the Comaneci device. Two patients had acute ruptured posterior communicating aneurysms and one patient was treated electively for a carotico-ophthalmic aneurysm. Excellent occlusion of all three aneurysms was obtained. One patient developed a distal middle cerebral artery clot, that was treated with intravenous aspirin, with minor neurological consequences. These early results show that the Comaneci device can be used to achieve good cerebral aneurysm occlusion. Vessel patency is maintained throughout the procedure with potential advantages over conventional balloon assisted coiling.

Difficult indirect carotid-cavernous fistulas – alternative techniques to gaining access for treatment

Aims Carotid-cavernous fistulas (CCFs) are abnormal communications between the carotid arterial system and the cavernous sinus that occur mainly in elderly. Occasionally, treatment of indirect CCFs with conventional endovascular approach through large veins or the inferior petrosal sinus may not be possible. In these cases, a direct surgical cut down on to the superior ophthalmic vein (SOV) is necessary. We describe three such cases of embolization of CCFs through SOV, and their results. Methods A retrospective case notes review of treated patients over the past 10 years in one tertiary center constituted our methodology. Results The fistulas in two cases were successfully coiled with complete obviation of symptoms and signs. The third case was complicated due to difficulty in canulating a deeply seated vein and so had to be abandoned and catheterized through contralateral superior petrosal sinus and treated with liquid embolic material Onyx® successfully. Conclusion In cases where conventional access to the cavernous sinus may not be possible due to local variations of anatomy, multidisciplinary surgical approaches via the SOV provide an alternative route to successfully and safely close a CCF. However, unexpected anatomical variations could also be encountered within the SOV for which the surgeon should be prepared.

Comment on: Carotid-cavernous fistula: current concepts in aetiology, investigation and management

We have read with great interest the article by Henderson and Miller regarding the endovascular management of dural carotid-cavernous fistulas with a transvenous approach via the superior ophthalmic vein [1]. An anterior orbitotomy allows the superior ophthalmic vein to be identified, and a venous catheter inserted and advanced into the cavernous sinus with a success rate for transvenous procedures reported at around 80% [1]. Carotid-cavernous fistulas are associated with a dilatation of the superior ophthalmic vein, however, challenges to their identification and cannulation arise in cases of small, fragile, anomalous or thrombosed veins [2]. Based on our experience, we would like to report the use of an intraoperative Valsalva manoeuvre to assist cannulation of the superior ophthalmic vein. A 60-year-old gentleman underwent endovascular repair with a transvenous approach via the superior ophthalmic vein of a dural carotid-cavernous fistula. An anterior orbitotomy approach identified the superior ophthalmic vein, although cannulation proved challenging as the vein was small and fragile. An intraoperative anaesthetist controlled Valsalva manoeuvre was performed, which produced a prominent dilatation of the vein and enabled a successful cannulation. This technique may also be used to identify a small or anomalous superior ophthalmic vein. Head and neck surgery may be associated with lifethreatening post-operative bleeding. Subsequently, numerous publications discuss intraoperative Valsalva manoeuvre and Trendelenburg positioning to assist identification of bleeding vessels [3, 4]. To our knowledge, this is the first report of intraoperative Valsalva manoeuvre used to assist ophthalmic vein cannulation, and hope this may be considered in similar challenging cases.

Kinematic measures provide useful information after intracranial aneurysm treatment

Introduction Current methods of assessing the outcomes of intracranial aneurysm treatment for aneurysmal subarachnoid haemorrhage are relatively insensitive, and thus unlikely to detect subtle deficits. Failures to identify cognitive and motor outcomes of intracranial aneurysm treatment might prevent delivery of optimal post-operative care. There are also concerns over risks associated with using intracranial aneurysm treatment as a preventative measure. Methods We explored whether our kinematic tool would yield useful information regarding motor/cognitive function in patients who underwent intracranial aneurysm treatment for aneurysmal subarachnoid haemorrhage or unruptured aneurysm. Computerised kinematic motor and learning tasks were administered alongside standardised clinical outcome measures of cognition and functional ability, in 10 patients, as a pilot trial. Tests at post-intracranial aneurysm treatment discharge and six-week follow-up were compared to see which measures detected changes. Results Kinematic tests captured significant improvements from discharge to six-week follow-up, indexed by reduced motor errors and improved learning. Increased Addenbrooke’s Cognitive Examination-Revised scores reflected some recovery of memory function for most individuals, but other standardised cognitive measures, functional outcome scores and a psychological questionnaire showed no changes. Conclusions Kinematic measures can identify variation in performance in individuals with only slightly improved abilities post-intracranial aneurysm treatment. These measures may provide a sensitive way to explore post-operative outcomes following intracranial aneurysm treatment, or other similar surgical procedures.

Lateral ventricle haemangioblastoma: the role of perfusion scanning and embolisation in diagnosis and management

We present the case of a 24-year-old man who presented with vertigo and right-sided weakness. Subsequent imaging demonstrated a lateral ventricle haemangioblastoma. This is the first case ever to be treated with surgical excision augmented by preoperative endovascular embolisation, as illustrated with perfusion CT scanning performed pre-embolisation and postembolisation. We present the case followed by a summary of the previously published cases and a discussion of the advantages of perfusion scanning and endovascular embolisation in these highly vascular (and therefore potentially dangerous) lesions.