William McAuliffe

Endovascular treatment of complex aneurysms at the vertebrobasilar junction with flow-diverting stents: initial experience.

BACKGROUND Large or giant complex vertebrobasilar junction aneurysms have a dismal natural history and are often challenging to treat with standard endovascular or neurosurgical techniques. OBJECTIVE To report initial experience with endovascular treatment of these aneurysms using flow-diverting stents (FDS). METHODS Ten patients with FDS treatment of complex vertebrobasilar junction aneurysms were collected from 4 large cerebrovascular centers. Clinical/angiographic presentation and outcome were retrospectively analyzed. RESULTS Of 10 aneurysms, 7 presented with brainstem compression, 2 with ischemia, and 1 with subarachnoid hemorrhage, and 3 were recurrent after stent-assisted treatments. Eight were giant. Morphology was fusiform in 5, fusiform dissecting in 1, and multilobulated saccular in 4. Six were partially thrombosed. In addition to FDS (mean number of devices, 3.9; range, 1-9), contralateral vertebral artery sacrifice and adjunctive coiling were performed in 9 and 5 of the 10 patients, respectively. At follow-up, 5 of 10 were completely occluded, 4 showed minimal residual filling, and 1 was retreated with an additional FDS. Postinterventionally, worsening mass effect and ischemic complications were seen in 2 and 4 of 10, respectively. Clinical outcome was good in 6 (modified Rankin Scale score, 0-2). Four fatalities were related to sequelae of subarachnoid hemorrhage, late FDS thrombosis, progressive mass effect, and delayed intracranial hemorrhage. CONCLUSION FDS may be used to treat complex vertebrobasilar junction aneurysms with overall good angiographic outcome. A combined reconstructive/deconstructive approach appears useful to avoid endoleaks. FDS strategies, like other endovascular and neurosurgical approaches to these lesions, are associated with significant risk and therefore should be reserved for those cases in which alternative approaches either are deemed unsafe or are likely to be ineffective. ABBREVIATIONS FDS, flow-diverting stentPED, Pipeline Embolization DeviceSAH, subarachnoid hemorrhageVA, vertebral arteryVBJ, vertebrobasilar junction.

Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre.

Background and Purpose: Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service. Methods: We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0–1, or a decrease from baseline of ≤8, at 24 h after stroke onset. Results: Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different. Conclusion: Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.

Spinal arachnoiditis as a consequence of aneurysm-related subarachnoid haemorrhage

Only a few case reports currently exist regarding symptomatic spinal arachnoiditis following aneurysm‐related subarachnoid haemorrhage. We present three patients who developed symptomatic spinal arachnoiditis following spontaneous aneurysm rupture. Following initial aneurysm and subarachnoid haemorrhage management (including ventriculo‐peritoneal shunt placement), all three patients developed gradually worsening neurological abnormalities, and subsequent imaging demonstrated spinal arachnoiditis. Despite spinal decompression, all three patients experienced progressively worsening neurological decline.

Mechanical thrombectomy for anterior circulation stroke: 5-year experience in a statewide service with differences in pretreatment time metrics across two hospitals sites

Objective To audit our institutional mechanical thrombectomy (MT) outcomes for acute anterior circulation stroke and examine the influence of workflow time metrics on patient outcomes. Methods A database of 100 MT cases was maintained throughout May 2010—February 2015 as part of a statewide service provided across two tertiary hospitals (H1 and H2). Patient demographics, stroke and procedural details, blinded angiographic outcomes, and 90-day modified Rankin Scale (mRS) scores were recorded. The following time points in stroke treatment were recorded: stroke onset, hospital presentation, CT imaging, arteriotomy, and recanalization. Statistical analysis of outcomes, predictors of outcome, and differences between the hospitals was carried out. Results Thrombolysis in Cerebral Infarction (TICI) 2b/3 reperfusion was 79%. Forty-nine per cent of patients had good clinical outcomes (mRS 0–2). In a subgroup analysis of 76 patients with premorbid mRS 0–1 and first CT performed ≤4.5 h after stroke onset, 60% had good clinical outcomes. Patient and disease characteristics were matched between the two hospitals. H1 had shorter times between hospital presentation and CT (32 vs 55 min, p=0.01), CT and arteriotomy (33 vs 69 min, p=0.00), and stroke onset and recanalization (198 vs 260 min, p=0.00). These time metrics independently predicted good clinical outcome. Median days spent at home in the first 90 days was greater at H1 (61 vs 8, p=0.04) than at H2. A greater proportion of patients treated at H1 were independent (mRS 0–2) at 90 days (54% vs 42%); however, this was not statistically significant (p=0.22). Conclusions Outcomes similar to randomized controlled trials are attainable in ‘real-world’ settings. Workflow time metrics were independent predictors of clinical outcome, and differed between the two hospitals owing to site-specific organizational differences.

CT perfusion in acute stroke calls: A pictorial review and differential diagnoses

CT perfusion is increasingly utilised in hyperacute stroke to facilitate diagnosis and patient selection for reperfusion therapies. This review article demonstrates eight examples of how CT perfusion can be used to diagnose stroke mimics and small volume infarcts, which can be easily missed on non‐contrast CT, and to suggest the presence of an ischaemic penumbra. Radiologists involved in stroke management must understand the importance of rapid imaging acquisition and be confident in the prospective interpretation of this powerful diagnostic tool as we move into a new era of hyperacute stroke care.

CT perfusion can delineate lacunar infarcts in acute stroke calls

Lacunar infarction accounts for approximately one quarter of all ischemic strokes but can be difficult to diagnose on noncontrast CT and clinical grounds.1 Diffusion-weighted imaging MRI has traditionally been considered the optimal modality for imaging confirmation1 but can be difficult to obtain acutely. CT perfusion has been increasingly used in hyperacute stroke and has shown promise in improving detection of lacunar infarcts.2 We present 4 patients in whom CT perfusion was performed using a 320-slice scanner (Aquilion ONE Vision, Toshiba, Japan) and Ultravist 370 (iopromide, Bayer, Switzerland) injected at 4 mL/s for 50 mL. Multiplanar reconstruction of perfusion data was performed using commercially available software (Vitrea 6.6.2036.1, Vital Images, Minnetonka, MN). Time from stroke onset to CT perfusion is presented in the table.

Micro-bubble transcranial Doppler ultrasound for exclusion of right-to-left circulatory shunts: Why should we provide the service?

Micro‐bubble transcranial Doppler ultrasound is a study used for the identification and quantification of a right‐to‐left circulatory shunt which can be implicated in stroke. It is an underused technique in many centres. Micro‐bubble transcranial Doppler ultrasound is non‐invasive, innocuous, quick and requires no fasting or sedation. Published literature also suggests almost perfect concordance with transoesophageal echocardiography and potentially greater sensitivity. We believe there is a great potential for neuroradiologists to provide this service as part of the diagnostic workup in patients with cryptogenic stroke.

Use of flat panel DynaCT myelography to locate the site of CSF leak

Spontaneous intracranial hypotension is often treated conservatively or with epidural blood patch. Patients who are resistant to these treatments require accurate imaging localisation of the site of cerebrospinal fluid (CSF) leak for surgical repair. We describe two patients where MRI, CT myelography and MRI gadolinium myelography showed evidence of a large volume of epidural CSF, but failed to identify the pressure site of leak. Subsequently, DynaCT (Siemens, Erlangen, Germany) accurately identified the site with confidence in both cases, confirmed at surgery. This technique of using a flat panel detector‐based, angiographic system to produce high quality, high‐contrast multiplanar CT images for detecting the source of rapid CSF leak is detailed.

Transvenous coil embolization with intra-operative cone beam CT assistance in the treatment of hypoglossal canal dural arteriovenous fistulae

Background Hypoglossal canal dural arteriovenous fistulae (HC-dAVF) are a rare subtype of skull base fistulae involving the anterior condylar confluence or anterior condular vein within the hypoglossal canal. Transvenous coil embolization is a preferred treatment strategy, however delineation of fistula angio-architecture during workup and localization of microcatheter tip during embolization remain challenging on planar DSA. For this reason, our group have utilized intra-operative cone beam CT (CBCT) and selective cone beam CT angiography (sCBCTA) as adjuncts to planar DSA during workup and treatment. The purpose of this article is to present our experience in the treatment of HC-dAVF using transvenous coil embolization (TVCE) with cone beam CT assistance, describing our technique as well as presenting our angiographic and clinical outcomes. Methods Ten patients with symptomatic HC-dAVF were treated using TVCE with intra-operative cone beam CT assistance. Prospectively collected data regarding clinical and angiographic results and complication rates was recorded and reviewed. Results Complication-free fistula occlusion was achieved in our entire patient cohort. The dominant symptom of pulsatile tinnitus resolved in all 10 patients. Conclusions This study demonstrates that TVCE with CBCT assistance is a highly effective treatment option for HC-dAVF, achieving complication-free fistula occlusion in our entire patient cohort. We have found low-dose sCBCTA and CBCT to be an extremely useful adjunct to planar DSA imaging during both workup and treatment of these rare fistulae.

Fibroadipose vascular anomaly treated with sirolimus: Successful outcome in two patients

Fibroadipose vascular anomaly (FAVA) is a rare, complex mesenchymal malformation combining fibrofatty replacement of the affected muscles and slow‐flow vascular malformation. The condition is characterized by localized swelling, severe pain, phlebectasia, and contracture of the affected limb. Treatment paradigms are not well established for this rare, recently recognized condition. We report two cases of FAVA in which treatment with sirolimus produced rapid, dramatic improvement in pain and quality of life.