Search

BackgroundIrregular pulsation of aneurysmal wall detected by four-dimensional CT angiography (4D-CTA) has been described as a novel imaging feature of aneurysm vulnerability. Our study aimed to investigate whether irregular pulsation is associated with symptomatic and ruptured intracranial aneurysms (IAs).MethodsThis retrospective study included consecutive patients with IAs who underwent 4D-CTA from January 2018 to July 2021. IAs were categorized as asymptomatic, symptomatic or ruptured. The presence of irregular pulsation (defined as a temporary focal protuberance ≥1 mm on more than three successive frames) was identified on 4D-CTA movies. Univariate and multivariate analyses were used to identify the parameters associated with aneurysm symptomatic or ruptured status.ResultsOverall, 305 patients with 328 aneurysms (37 ruptured, 60 symptomatic, 231 asymptomatic) were included. Ruptured and symptomatic IAs were significantly larger in size compared with asymptomatic IAs (median (IQR) 6.5 (5.1–8.3) mm, 7.0 (5.5–9.7) mm vs 4.7 (3.8–6.3) mm, p=0.001 and pConclusionIn a large cohort of patients with IAs detected by 4D-CTA, the presence of irregular pulsation was independently associated with aneurysm symptomatic and ruptured status.

BackgroundThe transcirculation approach (TCA) for stent-assisted coiling (SAC) of intracranial aneurysms may be useful for certain wide-neck bifurcation aneurysms as well as those with acute-angle efferent branches.ObjectiveTo describe a multicenter experience using the TCA for SAC.MethodsA multicenter, retrospective study (2016–2020) of aneurysm treatment using SAC via the TCA. Angiographic outcome was scored using the Raymond Scale (adequate occlusion 1 and 2), and clinical outcome was scored using a modified Rankin Scale (good outcome 0–2)ResultsTwenty-nine patients with 29 aneurysms were included (62.1% female; average age 61; 89.7% unruptured; 13.8% previously treated; average dome size 6.4 mm; average neck 4.4 mm). Aneurysm locations included internal carotid artery–fetal posterior cerebral artery (n=4), internal carotid artery terminus (n=4), anterior communicating artery (n=8), vertebral artery–posterior inferior cerebellar artery (n=2), and basilar tip (n=11). The TCA used communicating arteries (93.1%; average 1.6 mm), intermediate catheters (51.7%), jailing technique (62.1%), and staged procedures (10.3%). The most common stent was the Neuroform Atlas (Stryker; 69%). Immediate adequate occlusion was obtained in 75.9%, and five patients with inadequate occlusion progressed to adequate occlusion at follow-up. One (3.4%) procedural complication occurred: a watershed stroke in the setting of baseline four-vessel extracranial disease. Two patients had a poor outcome unrelated to the TCA. The majority of patients (86.4%) had a good clinical outcome. One case of in-stent stenosis due to non-compliance with medication was seen, which resolved with medication resumption.ConclusionsThe TCA for SAC can be performed for a variety of aneurysms with a low complication rate and good clinical outcomes.

BackgroundInfection from the SARS-CoV-2 virus has led to the COVID-19 pandemic. Given the large number of patients affected, healthcare personnel and facility resources are stretched to the limit; however, the need for urgent and emergent neurosurgical care continues. This article describes best practices when performing neurosurgical procedures on patients with COVID-19 based on multi-institutional experiences.MethodsWe assembled neurosurgical practitioners from 13 different health systems from across the USA, including those in hot spots, to describe their practices in managing neurosurgical emergencies within the COVID-19 environment.ResultsPatients presenting with neurosurgical emergencies should be considered as persons under investigation (PUI) and thus maximal personal protective equipment (PPE) should be donned during interaction and transfer. Intubations and extubations should be done with only anesthesia staff donning maximal PPE in a negative pressure environment. Operating room (OR) staff should enter the room once the air has been cleared of particulate matter. Certain OR suites should be designated as covid ORs, thus allowing for all neurosurgical cases on covid/PUI patients to be performed in these rooms, which will require a terminal clean post procedure. Each COVID OR suite should be attached to an anteroom which is a negative pressure room with a HEPA filter, thus allowing for donning and doffing of PPE without risking contamination of clean areas.ConclusionBased on a multi-institutional collaborative effort, we describe best practices when providing neurosurgical treatment for patients with COVID-19 in order to optimize clinical care and minimize the exposure of patients and staff.

BackgroundAnterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs.MethodsThe CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990–2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed.Results60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs.ConclusionMost ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.

BackgroundUse of the radial artery as an access site for neurointerventional procedures is gaining popularity after several studies in interventional cardiology have demonstrated superior patient safety, decreased length of stay, and patient preference compared with femoral artery access. The transradial approach has yet to be characterized for intraoperative cerebral angiography.ObjectiveTo report a multicenter experience on the use of radial artery access in intraoperative cerebral angiography, including case series and discussion of technical nuances.Methods27 patients underwent attempted transradial cerebral angiography betweenMay 2017 and May 2019. Data were collected regarding technique, patient positioning, vessels selected, technical success rate, and access site complications.Results24 of the 27 patients (88.8%) underwent successful transradial intraoperative cerebral angiography. 18 patients (66.7%) were positioned supine, 6 patients (22.2%) were positioned prone, 1 patient (3.7%) was positioned lateral, and 2 patients (7.4%) were positioned three-quarters prone. A total of 31 vessels were selected including 13 right carotid arteries (8 common, 1 external, 4 internal), 11 left carotid arteries (9 common and 2 internal), and 6 vertebral arteries (5 right and 1 left). Two patients (7.4%) required conversion to femoral access in order to complete the intraoperative angiogram (1 due to arterial vasospasm and 1 due to inadvertent venous catheterization). One procedure (3.7%) was aborted because of inability to obtain the appropriate fluoroscopic views due to patient positioning. No patient experienced stroke, arterial dissection, or access site complication.ConclusionsTransradial intraoperative cerebral angiography is safe and feasible with potential for improved operating room workflow ergonomics, faster patient mobility in the postoperative period, and reduced costs.

BackgroundPediatric acute ischemic stroke with underlying large vessel occlusion is a rare disease with significant morbidity and mortality. There is a paucity of data about the safety and outcomes of endovascular thrombectomy in these cases, especially with modern devices.MethodsWe conducted a retrospective review of all pediatric stroke patients who underwent endovascular thrombectomy in nine US tertiary centers between 2008 and 2017.ResultsNineteen patients (63.2% male) with a mean (SD) age of 10.9(6) years and weight 44.6 (30.8) kg were included. Mean (SD) NIH Stroke Scale (NIHSS) score at presentation was 13.9 (5.7). CT-based assessment was obtained in 88.2% of the patients and 58.8% of the patients had perfusion-based assessment. All procedures were performed via the transfemoral approach. The first-pass device was stentriever in 52.6% of cases and aspiration in 36.8%. Successful revascularization was achieved in 89.5% of the patients after a mean (SD) of 2.2 (1.5) passes, with a mean (SD) groin puncture to recanalization time of 48.7 (37.3) min (median 41.5). The mean (SD) reduction in NIHSS from admission to discharge was 10.2 (6.2). A good neurological outcome was achieved in 89.5% of the patients. One patient had post-revascularization seizure, but no other procedural complications or mortality occurred.ConclusionsEndovascular thrombectomy is safe and feasible in selected pediatric patients. Technical and neurological outcomes were comparable to adult literature with no safety concerns with the use of standard adult devices in patients as young as 18 months. This large series adds to the growing literature but further studies are warranted.

ObjectiveTo evaluate the safety and effectiveness of the Flow Redirection Endoluminal Device (FRED) flow diverter in support of an application for Food and Drug Administration approval in the USA.Methods145 patients were enrolled in a prospective, single-arm multicenter trial. Patients with aneurysms of unfavorable morphology for traditional endovascular therapies (large, wide-necked, fusiform, etc) were included. The trial was designed to demonstrate non-inferiority in both safety and effectiveness, comparing trial results with performance goals (PGs) established from peer-reviewed published literature. The primary safety endpoint was death or major stroke (National Institutes of Health Stroke Scale score ≥4 points) within 30 days of the procedure, or any major ipsilateral stroke or neurological death within the first year. The primary effectiveness endpoint was complete occlusion of the target aneurysm with ≤50% stenosis of the parent artery at 12 months after treatment, and in which an alternative treatment of the target intracranial aneurysm had not been performed.Results145 patients underwent attempted placement of a FRED device, and one or more devices were placed in all 145 patients. 135/145 (93%) had a single device placed. Core laboratory adjudication deemed 106 (73.1%) of the aneurysms large or giant. A safety endpoint was experienced by 9/145 (6.2%) patients, successfully achieving the safety PG of 46% aneurysm occlusion was also achieved, with the effectiveness endpoint being met in 80/139 (57.6%)ConclusionAs compared with historically derived performance benchmarks, the FRED flow diverter is both safe and effective for the treatment of appropriately selected intracranial aneurysms.Clinical registration numberNCT01801007

BackgroundDural arteriovenous fistulae (dAVFs) comprise 10–15% of all intracranial arteriovenous malformations. The goal of surgical or endovascular intervention is complete obliteration of the fistulous connection(s). In cases where dAVF venous drainage is separate from normal cortical drainage, transvenous embolization can provide fast and effective fistula obliteration.ObjectiveTo describe a new method of efficient transvenous embolization (the ‘dual microcatheter technique’) for the treatment of dAVFs.MethodsThree patients with dAVFs were treated using the dual microcatheter technique for transvenous embolization. Two microcatheters were placed in the distal aspect of the dAVF venous pouch, after which coil embolization reduced fistula flow, and liquid embolic agent injection with reflux into arterial feeders completed the obliteration of the fistula.ResultsLesion grade ranged from Borden–Shucart grades 2 through 3. In all cases, dAVF venous drainage was isolated from the normal cerebral venous drainage. Dual microcatheter transvenous embolization was successful in all patients, with non-target embolization and no new postoperative deficits. At the last follow-up, all three patients were symptom-free without evidence of radiographic recurrence.ConclusionsThe dual microcatheter technique of transvenous dAVF embolization is safe and feasible in cases where dAVF venous outflow is isolated from normal cerebral venous drainage.

Background Blood blister type aneurysms (BBAs) and pseudoaneurysms create a unique treatment challenge. Despite many advances in open surgical and endovascular techniques, this subset of patients retains relatively high rates of morbidity and mortality. Recently, BBAs have been treated with flow-diverting stents such as the Pipeline Embolization Device (PED) with overall positive results. Methods Four patients presented with dissecting internal carotid artery (ICA) aneurysms treated with the PED (two BBAs presenting with subarachnoid hemorrhage (SAH), two pseudoaneurysms after injury during endoscopic trans-sphenoidal tumor surgery). Results Three patients had a successful angiographic and neurological outcome. One patient with a BBA re-ruptured during initial PED placement, again in the postoperative period, and later died. Primary PED treatment involved telescoping stents in two patients and coil embolization supplementation in one patient. Conclusions The PED should be used selectively in the setting of acute SAH. Dual antiplatelet therapy can complicate hydrocephalus management, and the lack of immediate aneurysm occlusion creates the risk of short-term re-rupture. PED treatment for iatrogenic ICA pseudoaneurysms can provide a good angiographic and neurological outcome.

Objective The risk of seizures after malignant middle cerebral artery (MCA) infarction with decompressive hemicraniectomy (DHC) is uncertain. Also unknown is how this complication influences survivors’ recovery and quality of life. Methods We retrospectively reviewed medical charts of all patients admitted to Harborview Medical Center between 1 January 2002 and 31 June 2011 for space-occupying MCA ischaemic stroke and who underwent DHC. Survivors and their surrogates were invited to participate in a telephone or in-person interview. Results Fifty-five patients were followed for a median of 311 days (IQR 134–727). Twenty-seven patients (49%) had seizures, 25 (45%) developed epilepsy and 21 (38%) achieved moderate disability or better (modified Rankin Scale score ≤3) by 1 year after stroke onset. The only factor significantly associated with seizure occurrence was male gender. Median time from stroke to first seizure was 222 days, with a cluster of first seizures within weeks after cranioplasty; only two of the first seizures occurred right around the time of stroke onset. Follow-up time was significantly longer for patients with seizures (605 days, IQR 297–882) than for those without (221 days, IQR 104–335). Of the 20 patients interviewed, 12 achieved moderate disability or better, 15 experienced a seizure with 6 indicating the seizure was a major drawback. Regardless, all 20 would have chosen DHC again. Conclusions In this case series, patients were at high risk of developing seizures after malignant MCA stroke with DHC, especially after cranioplasty. Assuming these findings are replicated, means should be sought to reduce the occurrence of this complication.

Background Flat panel detector CT (FD-CT), three-dimensional image overlay and navigation software on contemporary fluoroscopic units generate less radiation dose while performing imaging of comparable quality to conventional CT. They can superimpose MR and CT datasets and can accurately guide percutaneous procedures providing live instrument visualization and the capability of re-imaging without patient transfer. These techniques, however, have been minimally used for accessing the head. Materials and methods Using an Allura Xper FD20 unit (Philips Healthcare Andover, Massachusetts, USA), three-dimensional image overlay and FD-CT navigation were used for percutaneous n-butyl cyanoacrylate (nBCA) embolization of an intraorbital mass in a 69-year-old man. Results Three-dimensional image overlay provides accurate anatomical relationships between the optic nerve and vascular portions of the mass. Percutaneous nBCA was technically successful without non-target embolization and with no significant bleeding encountered during operative resection. Conclusion FD-CT navigation and three-dimensional image overlay provide accurate instrument guidance and spatial resolution comparable with current neuro-navigation systems while also providing real time instrument position and the ability to re-image without moving the patient. These are features not available with other types of neuro-navigation.

Introduction Arteriovenous malformations (AVMs) are a heterogeneous group of lesions that can rupture and cause severe morbidity or even death. However, there is no consensus with respect to their natural history or proper treatment. When safely feasible, microsurgical resection is the primary treatment, but certain features like size and location can render lesions unresectable. Embolization can be performed to obliterate high-risk features like aneurysms or reduce the lesion nidus to make it more amenable to stereotactic radiosurgery. This study describes the experience at two centers with embolization performed to selectively target aneurysms associated with AVMs. Materials and methods Prospectively maintained records from two medical centers were retrospectively analyzed to identify patients undergoing targeted embolization for AVM aneurysm between January 2002 and February 2015. Patients were selected for analysis if embolization was only targeted at the aneurysm. Patients undergoing repeat embolization or surgery after targeted embolization were excluded from analysis. For included patients, age, gender, and presenting symptom were recorded. Spetzler-Martin and supplemental AVM scores were recorded, as were the components of each of these scales. Aneurysm location (feeding artery versus nidus), size, treatment type, technical outcome, and any complications were recorded. Follow-up data examined were hemorrhage, seizure, and modified Rankin score at 30 days, 90 days, 1 year, and point of last contact. Chi-square tests were performed to identify any correlation between demographic, treatment, and clinical outcome variables. Results 31 patients (14 men, 7 women; mean age at treatment 43.8 years, IQR 23.7–43.8) were identified who met inclusion criteria. Mean aneurysm size was 5.6 mm. 16 (51.6%) aneurysms were present in arterial feeders, while 15 (49.4%) were located in the AVM nidus. 18 (81.8%) presented with intracranial hemorrhage_16 (51.6%) with parenchymal hemorrhage and 19 (61.3%) with subarachnoid or intraventricular hemorrhage. The remaining 4 (18.2%) presented with seizures. 24 (77.4%) AVMs had deep drainage, 23 (74.2%) involved eloquent territory, and 11 (35.5%) demonstrated diffuse nidus. 13 (41.9%) were treated with Onyx, 13 (41.9%) with coils, 3 (9.7%) with n-BCA, and 2 with ethanol (6.5%). Technical success occurred in all cases. 1 procedure was complicated by thrombus formation and was successfully treated with abciximab, 1 aneurysm ruptured during coiling but was further coiled without incident, and another procedure was complicated by dissection that was self-limited and caused no untoward effects. 23 (74.2%) lesions were subsequently treated with stereotactic radiosurgery. No lesions hemorrhaged following treatment. 1 patient (4.5%) developed seizures after treatment after presenting with hemorrhage. Mean follow-up time was 759 days (IQR 125–1167). All patients had improved mRS at each point of follow up. Lesions with diffuse nidus were more likely to have complication during embolization (OR 6.8, p = 0.037). No other statistically significant relationships were found. Conclusion AVMs are complex lesions whose natural history and optimal treatment are incompletely understood. For unresectable lesions with aneurysms, targeted aneurysm embolization appears to be safe and effective. More formal analysis of this approach and direct comparison to other forms of treatment are warranted. Disclosures M. Alexander: None. D. Cooke: None. D. Hallam: None. S. Hetts: None. L. Kim: None. H. Kim: None. B. Ghodke: None.

A 26-year-old patient with recurrent choriocarcinoma of the testis presented with headache and progressive left homonymous hemianopsia. On initial MRI a grade 4 arteriovenous malformation (AVM) was identified in the right occipital lobe, which was further characterized by catheter angiography. Continued worsening of the headache in the following days prompted a follow-up MRI, which revealed a new T2 hypointense nodule and adjacent vasogenic edema in the periphery of the AVM. A follow-up MRI showed a marked increase in the size of the nodule with intrinsic enhancement and worsening perilesional edema. Based on the imaging evolution, the nodule was diagnosed as a metastasis and the patient was started on chemotherapy and radiotherapy. One week after the MRI he developed a sudden hemorrhage within the mass requiring decompression craniectomy and resection of both AVM and tumor. The histopathology of the resected mass confirmed the diagnosis of choriocarcinoma metastasis to the AVM.

Introduction: Among the sequelae of aneurysmal SAH are vasospasm and hydrocephalus. This study aims to assess whether intraventricular tissue plasminogen activator (tPA) results in fewer angioplasties and/or CSF shunting procedures. Methods: 41 patients (group A, Hunt and Hess (HH) 3–5) from 2007 to 2008 received intraventricular tPA and lumbar drainage for a minimum of 5 days (range 5–7 days) and were compared …