Prevention is better than cure

2:54 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

A superb study and a highly relevant one...
The technology, infrastructure and the medical services have decreased the fatality in stroke. while this does lead to independence for ADL and professional activities also in some cases, many stay dependent, putting a burden on the family and the society.
What we have to do is not just to improve the post-event medical facilities, but to improve the pre-event medical system so that stroke does not happen. That would be our true victory....and sadly no business for me, an interventional neuroradiologist.

Remarkable Decline in Ischemic Stroke Mortality Is not Matched by Changes in Incidence [Original Contributions]:
Background and Purpose—
In Western Europe, mortality from ischemic stroke (IS) has declined over several decades. Age–sex-specific IS mortality, IS incidence, 30-day case fatality, and 1-year mortality after hospital admission are essential for explaining recent trends in IS mortality in the new millennium.
Methods—
Data for all IS deaths (1980–2010) in the Netherlands were grouped by year, sex, and age. A joinpoint regression was fitted to detect points in time at which significant changes in the trends occur. By linking nationwide registers, a cohort of patients first admitted for IS between 1997 and 2005 was constructed and age–sex-specific 30-day case fatality and 1-year mortality were computed. IS incidence (admitted IS patients and out-of-hospital IS deaths) was computed by age and sex. Mann–Kendall tests were used for trend evaluation.
Results—
IS mortality declined continuously between1980 and 2000 with an attenuation of decline in the 1990s in some of the age–sex groups. A remarkable decline in IS mortality after 2000 was observed in all age–sex groups, except for young men. An improved decline in 30-day case fatality and in 1-year mortality was also observed in almost all age–sex groups. In contrast, IS incidence remained stable between 1997 and 2005 or even increased slightly.
Conclusions—
The recent remarkable decline in IS mortality was not matched by a decline in the number of incident nonfatal IS events. This is worrying, because IS is already a leading cause of adult disability, claiming a heavy human and economic burden. Prevention of IS is therefore now of the greatest importance.


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Is Intra-Arterial Thrombolysis Beneficial for M2 Occlusions? Subgroup Analysis of the PROACT-II Trial [Brief Report]

2:44 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

A very interesting article.....I have thought of doing IAT for such 'distal  MCA' occlusions often but somehow always found noninvasive management better -either IVT  or medical management as indicated...
The problem for me is the smaller infarct volume and relatively preserved clinical status of such patients, at least in my practice, and the complication rate associated with the IAT.
But of course 50+ % success rate is reasonably good....but in our center we have fairly good clinical  outcomes in such patient with IVT...
I am still not impressed in spite of this article...

Is Intra-Arterial Thrombolysis Beneficial for M2 Occlusions? Subgroup Analysis of the PROACT-II Trial [Brief Report]:
Rahme, R et al, Stroke ASAP Dec 2012
Background and Purpose—
The role of endovascular therapy for acute M2 trunk occlusions is debatable. Through a subgroup analysis of Prolyse in Acute Cerebral Thromboembolism-II, we compared outcomes of M2 occlusions in treatment and control arms.
Methods—
Solitary M2 occlusions were identified from the Prolyse in Acute Cerebral Thromboembolism-II database. Primary endpoints were successful angiographic reperfusion (TICI 2–3) at 120 minutes and functional independence (mRS 0–2) at 90 days.
Results—
Forty-four patients with solitary M2 occlusions, 30 in the treatment arm and 14 in the control arm, were identified. Successful reperfusion (TICI 2–3) was achieved in 53.6% and 16.7% of patients in the treatment and control arms, respectively (P=0.04). A favorable clinical outcome (mRS 0–2) was observed in 53.3% and 28.6%, respectively (P=0.19). Baseline characteristics were similar between the 2 groups.
Conclusions—
Intra-arterial thrombolysis may lead to a 3-fold increase in the rate of early reperfusion of solitary M2 occlusions and could potentially double the chance of a favorable functional outcome at 90 days.
Clinical Trial Registration—
This trial was not registered because enrollment began before July 1, 2005.


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Strategic coil placement at the mid-body of Pcom artery aneurysm

2:49 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Aneurysm come in all shape and sizes and at all locations.

This one was in a 42 years old female patient with Grade I SAH and a ruptured right PcomA aneurysm.

The anatomy was odd with a bulbous, rather blister like proximal part, then a narrowing, then the body, again a narrowing then a teat like portion. The Pcom, of course, had to arise from the aneurysm; specifically it came at the site of first narrowing mentioned.

The aneurysm was directed laterally and posteriorly and had a curved structure rather.

The proximal bulbous portion measured 2.67 mm in diameter with equal neck and the distal narrower portions 2 mm.

So, I used an Echelon and Xpedion –ten system- to access the aneurysm.

Then i was in a fix as to how to go about fixing the aneurysm.

I put in a 2x6 3D AXIUM in the mid part of the aneurysm beyond the Pcom origin. The coil loops did try to go in the distal teat but somehow the entire coil could be fit in there.

Angio showed complete cessation of flow within that portion, with contrast stasis in the teat and the Pcom stayed patent.

However in the native images, still some space appeared within the coil mesh, so I took an AXIUM 2x4 Helix coil and pushed in.

The loops went into the first coil and then started to come into the proximal portion. Somehow, the loops in this part stayed horizontal thus restructuring the inflow zone and contrast flowing into the pcom.

But the last loop could not be fit in and kept pushing the microcatheter tip into the arterial lumen.

So I left the procedure at that point and put my hands up.

The patient is fine, and we all are happy, but do not know what this anueurysm was ot how best to treat it.

My surgeon too told he would have clipped in the midpart  so the result would have been same, or rather bad as this looked to me like an infundibulum which had ruptured and the distal portion to me was nothing but a pseudoaneurysm.

I am keeping my fingers crossed. let’s see….

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Preoperative partial embolization of thoracic hemangioblastoma

5:55 PM Posted by Dr Subhash Kumar, MBBS, MD, DM



A middle aged woman had paraparesis since many years and had been operated six years back for a thoracic spinal tumor. However, the surgery was an ‘open and close’ one as the surgeon did not take out the tumor.
Post op, the patient rather received radiotherapy, and had been continuing with her paraparesis till one and half years back when her weakness increased and bowel -bladder symptoms appeared.
However she did not undergo any further treatment till now.
At present she had negligible motor power and with significant sensory loss as well in both lower limbs.
A fresh MRI showed the mid dorsal vascular tumor- which later turned out to be hemangioblastoma- with holocord syrinx.












Our neurosurgeon reoperated but could remove only one fourth of the tumor as it bled like hell intra-op.
Two days later I did the angiogram. The tumor was hypervascular and fed by posterior spinal arteries from right 9th and tenth thoracic pedicles.
The segmental arteries as well as the posterior spinals were extremely tortuous and all attempts of superselective microcatheterizations were futile.
RD 9 injection early and late
RD 10 injection early and late



Somehow, the microcatheter could be navigated to the RD9 feeder’s ostium from where PVA particles of size 300-500 microns were injected. This part of the tumor could be completely devascularised.
RD9 embolization early and late


However, the microcatheter could not be navigated even to the ostium of the other feeder.
Then I did the unthinkable. I injected particles right into the main segmental arterial trunk itself.
The capillary blush of the tumor could be decreased significantly and I stopped at this point, leaving the larger arterioles and arteries still patent and well visible.

I was pretty disappointed with the effort and conveyed the results to my surgeon.
However, he went ahead with surgery after two days and to everyone’s surprise almost the entire tumor was significantly devascularised. A small portion inferiorly was still vascular. The entire mass could be removed this time.
The patient has been sent home.
There was no objective neurological improvement till the time of discharge even though the patient said she felt better.

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Heparin dosing is associated with diffusion weighted imaging lesion load following aneurysm coiling

7:14 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Heparin dosing is associated with diffusion weighted imaging lesion load following aneurysm coiling: Background and purpose
Diffusion weighted imaging (DWI) may be used to evaluate post-coiling ischemia. Heparinization protocols for cerebral aneurysm coiling procedures differ among operators and centers, with little literature surrounding its effect on DWI lesions. The goal of this study was to determine which factors, including heparinization protocols, may affect DWI lesion load post-coiling.
Materials and methods
A review of 135 coiling procedures over 5 years at our centre was performed. Procedural data including length of procedure, number of coils used, stent or balloon assistance and operators were collected. Procedures were either assigned as using a bolus dose (>2000 U at any one time) or small aliquots of heparin (≤2000 U). Postprocedure DWI was reviewed and lesions were classified as small (< 5mm), medium (5–10 mm) or large (>10 mm). The cases were then classified into group 1 (≤5 small lesions) or group 2 (>5 small lesions or ≥1 medium or large lesion). Multivariate regression of the procedural variables for the two groups was calculated. A p value of <0.05 was considered significant.
Results
There were 78 procedures in group 1 and 57 procedures in group 2. Patients who received small aliquots (n=37) versus boluses of heparin (n=98) intraprocedurally had significantly greater frequency and size of DWI lesions (p=0.03). None of the other procedural variables was found to impact on lesion load.
Conclusions
More substantial DWI lesions were associated with small aliquots of heparin dosage compared with bolus doses. Heparin boluses should be preferentially administered during aneurysm coiling.


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The hyperdense vessel sign on CT predicts successful recanalization with the...

10:54 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

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via Journal of NeuroInterventional Surgery Online First by Froehler, M. T., Tateshima, S., Duckwiler, G., Jahan, R., Gonzalez, N., Vinuela, F., Liebeskind, D., Saver, J. L., Villablanca, J. P., For the UCLA Stroke Investigators on 5/22/12

Background

The success of mechanical clot retrieval for acute ischemic stroke may be influenced by the characteristics of the occlusive thrombus. The thrombus can be partly characterized by CT, as the hyperdense vessel sign (HVS) suggests erythrocyte-rich clot whereas fibrin-rich clot may be isodense. We hypothesized that the physical clot characteristics that determine CT density may also determine likelihood of retrieval with the Merci device.

Methods

We reviewed all acute stroke cases initially imaged with non-contrast CT before attempted Merci clot retrieval at a single center between 2004 and 2010. Each CT was blindly assessed for the presence or absence of the HVS, and post-retrieval angiograms were blindly assessed for reperfusion using the TICI scale.

Results

Of 67 patients analyzed (mean age 69; median NIHSS 19; 61% female), the HVS was seen in 42, and no HVS was present in 25. Successful recanalization was achieved in 79% of patients with the HVS (33/42), but in only 36% (9/25) of patients without HVS (p=0.001). The HVS was the only significant predictor of recanalization while accounting for age, treatment with IV-tPA, clot location, stroke etiology, time to treatment, and number of retrieval attempts.

Conclusion

The HVS in acute ischemic stroke was strongly predictive of successful recanalization using the Merci device. The HVS may indicate thrombi that are less adhesive compared with isodense clots that are more resistant to mechanical retrieval. The absence of HVS on pre-treatment CT may thus suggest the need for a more aggressive or alternative therapeutic approach.


 
 

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Clinical Significance of Impaired Cerebrovascular Autoregulation After Sever...

10:52 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

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via Stroke ASAP by Jaeger, M., Soehle, M., Schuhmann, M. U., Meixensberger, J. on 5/22/12

Background and Purpose—

The purpose of this study was to investigate the relationship between cerebrovascular autoregulation and outcome after aneurysmal subarachnoid hemorrhage.

Methods—

In a prospective observational study, 80 patients after severe subarachnoid hemorrhage were continuously monitored for cerebral perfusion pressure and partial pressure of brain tissue oxygen for an average of 7.9 days (range, 1.9–14.9 days). Autoregulation was assessed using the index of brain tissue oxygen pressure reactivity (ORx), a moving correlation coefficient between cerebral perfusion pressure and partial pressure of brain tissue oxygen. High ORx indicates impaired autoregulation; low ORx signifies intact autoregulation. Outcome was determined at 6 months and dichotomized into favorable (Glasgow Outcome Scale 4–5) and unfavorable outcome (Glasgow Outcome Scale 1–3).

Results—

Twenty-four patients had a favorable and 56 an unfavorable outcome. In a univariate analysis, there were significant differences in autoregulation (ORx 0.19±0.10 versus 0.37±0.11, P<0.001, for favorable versus unfavorable outcome, respectively), age (44.1±11.0 years versus 54.2±12.1 years, P=0.001), occurrence of delayed cerebral infarction (8% versus 46%, P<0.001), use of coiling (25% versus 54%, P=0.02), partial pressure of brain tissue oxygen (24.9±6.6 mmüHg versus 21.8±6.3 mmüHg, P=0.048), and Fisher grade (P=0.03). In a multivariate analysis, ORx (P<0.001) and age (P=0.003) retained an independent predictive value for outcome. ORx correlated with Glasgow Outcome Scale (r=–0.70, P<0.001).

Conclusions—

The status of cerebrovascular autoregulation might be an important pathophysiological factor in the disease process after subarachnoid hemorrhage, because impaired autoregulation was independently associated with an unfavorable outcome.


 
 

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Endovascular Treatment of Intracranial Unruptured Aneurysms: A Systematic Re...

10:50 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

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via Radiology current issue by Naggara, O. N., Lecler, A., Oppenheim, C., Meder, J.-F., Raymond, J. on 5/23/12

Purpose:

To report subgroup analyses of an updated systematic review on endovascular treatment of intracranial unruptured aneurysms (UAs); to compare types of embolic agents, adjunct techniques, and newer devices; and to identify potential risk factors for poor outcomes.

Materials and Methods:

Meta-Analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to prepare this article, and the literature was searched with PubMed and with EMBASE and Cochrane databases. Six eligibility criteria (procedural complications rates; at least 10 patients; saccular, nondissecting UAs; original study published in English or French between January 2003 and July 2011; methodological quality score > 6 [modified Strengthening and Reporting of Observational Studies in Epidemiology criteria]; a study published in a peer-reviewed journal) were used. End points included procedural mortality and unfavorable outcomes (death or modified Rankin Scale, Glasgow Outcome Scale, or World Federation of Neurosurgeons Scale at 1 month scores, all > 2). A fixed-effects model (Mantel-Haenszel) was used for pooled estimates of mortality and unfavorable outcomes; a random-effects model (DerSimonian-Laird) was used in case of heterogeneity.

Results:

Ninety-seven studies with 7172 patients (26 studies published July 2008 through July 2011) were included. Sixty-nine (1.8%) of 7034 patients died (fixed-effect weighted average; 99% confidence interval [CI]: 1.4%, 2.4%; Q value, 55.0; I2 = 0%). Unfavorable outcomes, including death, occurred in 4.7% (242 of 6941) of patients (99% CI: 3.8, 5.7; Q value, 128.3; I2 = 26.8%). Patients treated after 2004 had better outcomes (unfavorable outcome, 3.1; 99% CI: 2.4, 4.0) than patients treated during 2001–2003 (unfavorable outcome, 4.7%; 99% CI: 3.6%, 6.1%; P = .01) or in 2000 and before (unfavorable outcome, 5.6%; 99% CI: 4.7%, 6.6%; P < .001). Significantly higher risk was associated with liquid embolic agents (8.1%; 99% CI: 4.7%, 13.7%) versus simple coil placement (4.9%; 99% CI: 3.8%, 6.3%; P = .002). Unfavorable outcomes occurred in 11.5% (99% CI: 4.9%, 24.6%) of patients treated with flow diversion.

Conclusion:

Procedure-related poor outcomes occurred (4.7% of patients), risks decreased, and liquid embolic agents and flow diversion were associated with higher risks.

©RSNA, 2012

Supplemental material:http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12112114/-/DC1


 
 

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Closed-Cell Stent for Coil Embolization of Intracranial Aneurysms: Clinical ...

10:46 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

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via Publication Preview by Wakhloo, A. K., Linfante, I., Silva, C. F., Samaniego, E. A., Dabus, G., Etezadi, V., Spilberg, G., Gounis, M. J. on 5/24/12

BACKGROUND AND PURPOSE:

Recanalization is observed in 20–40% of endovascularly treated intracranial aneurysms. To further reduce the recanalization and expand endovascular treatment, we evaluated the safety and efficacy of closed-cell SACE.

MATERIALS AND METHODS:

Between 2007 and 2010, 147 consecutive patients (110 women; mean age, 54 years) presenting at 2 centers with 161 wide-neck ruptured and unruptured aneurysms were treated by using SACE. Inclusion criteria were wide-neck aneurysms (>4 mm or a dome/neck ratio ≤2). Clinical outcomes were assessed by the mRS score at baseline, discharge, and follow-up. Aneurysm occlusion was assessed on angiograms by using the RS immediately after SACE and at follow-up.

RESULTS:

Eighteen aneurysms (11%) were treated following rupture. Procedure-related mortality and permanent neurologic deficits occurred in 2 (1.4%) and 5 patients (3.4%), respectively. In total, 7 patients (4.8%) died, including 2 with reruptures. Of the 140 surviving patients, 113 (80.7%) patients with 120 aneurysms were available for follow-up neurologic examination at a mean of 11.8 months. An increase in mRS score from admission to follow-up by 1, 2, or 3 points was seen in 7 (6.9%), 1 (1%), and 2 (2%) patients, respectively. Follow-up angiography was performed in 120 aneurysms at a mean of 11.9 months. Recanalization occurred in 12 aneurysms (10%), requiring retreatment in 7 (5.8%). Moderate in-stent stenosis was seen in 1 (0.8%), which remained asymptomatic.

CONCLUSIONS:

This series adds to the evidence demonstrating the safety and effectiveness of SACE in the treatment of intracranial aneurysms. However, SACE of ruptured aneurysms and premature termination of antiplatelet treatment are associated with increased morbidity and mortality.


 
 

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Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guide...

10:37 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

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via Stroke current issue by Connolly, E. S., Rabinstein, A. A., Carhuapoma, J. R., Derdeyn, C. P., Dion, J., Higashida, R. T., Hoh, B. L., Kirkness, C. J., Naidech, A. M., Ogilvy, C. S., Patel, A. B., Thompson, B. G., Vespa, P., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Nursing, Council on Cardiovascular Surgery and Anesthesia, and Council on Clinical Cardiology on 5/25/12

Purpose—

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).

Methods—

A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.

Results—

Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

Conclusions—

aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.


 
 

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Single-Center Experience of Cerebral Artery Thrombectomy Using the TREVO Dev...

10:36 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

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via Stroke current issue by San Roman, L., Obach, V., Blasco, J., Macho, J., Lopez, A., Urra, X., Tomasello, A., Cervera, A., Amaro, S., Perandreu, J., Branera, J., Capurro, S., Oleaga, L., Chamorro, A. on 5/25/12

Background and Purpose—

We sought to explore the safety and efficacy of the new TREVO stent-like retriever in consecutive patients with acute stroke.

Methods—

We conducted a prospective, single-center study of 60 patients (mean age, 71.3 years; male 47%) with stroke lasting <8 hours in the anterior circulation (n=54) or <12 hours in the vertebrobasilar circulation (n=6) treated if CT perfusion/CT angiography confirmed a large artery occlusion, ruled out a malignant profile, or showed target mismatch if symptoms >4.5 hours. Successful recanalization (Thrombolysis In Cerebral Infarction 2b–3), good outcome (modified Rankin Scale score 0–2) and mortality at Day 90, device-related complications, and symptomatic hemorrhage (parenchymal hematoma Type 1 or parenchymal hematoma Type 2 and National Institutes of Health Stroke Scale score increment ≥4 points) were prospectively assessed.

Results—

Median (interquartile range) National Institutes of Health Stroke Scale score on admission was 18 (12–22). The median (interquartile range) time from stroke onset to groin puncture was 210 (173–296) minutes. Successful revascularization was obtained in 44 (73.3%) of the cases when only the TREVO device was used and in 52 (86.7%) when other devices or additional intra-arterial tissue-type plasminogen activator were also required. The median time (interquartile range) of the procedure was 80 (45–114) minutes. Good outcome was achieved in 27 (45%) of the patients and the mortality rate was 28.3%. Seven patients (11.7%) presented a symptomatic intracranial hemorrhage. No other major complications were detected.

Conclusions—

The TREVO device was reasonably safe and effective in patients with severe stroke. These results support further investigation of the TREVO device in multicentric registries and randomized clinical trials.


 
 

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Eligibility for Intravenous Recombinant Tissue-Type Plasminogen Activator Wi...

10:28 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

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via Stroke current issue by de los Rios la Rosa, F., Khoury, J., Kissela, B. M., Flaherty, M. L., Alwell, K., Moomaw, C. J., Khatri, P., Adeoye, O., Woo, D., Ferioli, S., Kleindorfer, D. O. on 5/25/12

Background and Purpose—

The publication of the European Cooperative Acute Stroke Study (ECASS III) expanded the treatment time to thrombolysis for acute ischemic stroke from 3 to 4.5 hours from symptom onset. The impact of the expanded time window on treatment rates has not been comprehensively evaluated in a population-based study.

Methods—

All patients with an ischemic stroke presenting to an emergency department during calendar year 2005 in the 17 hospitals that compromise the large 1.3 million Greater Cincinnati/Northern Kentucky population were included in the analysis. Criteria for exclusion from thrombolytic therapy are analyzed retrospectively for both the standard and expanded timeframes with varying door-to-needle times.

Results—

During the study period, 1838 ischemic strokes presenting to an emergency department were identified. A small proportion of them arrived in the expanded time window (3.4%) compared with the standard time window (22%). Only 0.5% of those who arrived in this timeframe met eligibility criteria for thrombolysis compared with 5.9% using standard eligibility criteria in the standard timeframe. These results did not vary significantly by repeated analysis varying the door-to-needle time or the expanded time window's exclusion criteria.

Conclusions—

In reality, the expanded time window for thrombolysis in acute ischemic stroke benefits few patients. If we are to improve recombinant tissue-type plasminogen activator administration rates, our focus should be on improving stroke awareness, transport to facilities with ability to administer thrombolysis, and familiarity of physicians with acute stroke treatment guidelines.


 
 

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Venous thrombosis presenting as subarachnoid hemorrhage

11:46 AM Posted by Dr Subhash Kumar, MBBS, MD, DM

  • 49 yrs, M
  • Seizures on the morning of admission
  • Vitals stable
  • No focal deficit
  • A CT done at admission showed SAH with flocculent surface hematoma in the left anterior frontal region…significantly there was no blood in the basal cisterns
  • image
  • NCCT at admission
  • image
  • image
  • Enlarged images of the NCCT
  • A cerebral DSA was done which showed thrombosis of anterior part of the superior sagittal sinus, partial thrombosis of the inferior sagittal sinus with hypoplastic left transverse and sigmoid sinuses
  • image
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  • image
  • Right ICA angiogram
  • image
  • image
  • Left ICA angiogram
  • image
  • Left and right vertebral angiogram
  • image
  • Right middle meningeal had anomalous origin from right petrous ICA
  • image
  • image
  • Left ECA angiogram showed blush from the middle meningeal artery in the region of the thrombosed superior sagittal sinus

Patient was put on heparin after this

  • image
  • NCCT next morning showed significant resolution of the SAH.
  • image
  • image
  • Enlarged images of the NCCT
  • The patient had an uneventful recovery and was discharged in a stable condition, on Warfarin.


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CLOTBUST sonothrombolysis of acute stroke

3:29 PM Posted by Dr Subhash Kumar, MBBS, MD, DM


CLOTBUST sonothrombolysis in acute stroke is a new addition in the armamentarium of physicians traeting these particularly challenging patients. It uses the simple premise of continuous transfer of ultrasonic wanes to the site of the clot in the blood vessel, which in a way soften ups the clot, such that intravenously given thrombolytic agents can work more effectively, resulting in better recanalisation rates, hence translating into better patient outcome.
We recently performed it on a patient with 3.5 hours of acute stroke onset, patient presenting with right sided weakness and Wernicke's aphasia, MRI showing acute left MCA territory diffusion restriction. As the DWI volume was not much and ASPECTS score was good, thrombolysis was performed along with continuous transcranial Doppler using a 2MHz probe, for two hours. After about 45 minutes, the patient responded, sat up himself and the weakness improved. Over the next 48 hours he continued to improve and had 4+/5 power with some aphasia; the aphasis improved over next two weeks and the patient is independent for ADL.
The TCD frame with the doppler probe in place

MRI showing diffusion restriction in left MCA territory


I started the doppler
The TCD wave at the end of the procedure ( 2 hours)
The patient sat up on his own









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Unassisted coiling of a wide necked aneurysm

3:05 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Wide necked aneurysms often are deemed to require assistance with balloon or stent during endovascular coiling, however, most of them do not require support as such, and well placed coils do the job.
Here is an example, wherein a wide neck Acom aneurysm incorporating one of the A2 segments, was coiled well without use of any balloon/stent.





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Long-Term Clinical and Imaging Follow-Up of Complex Intracranial Aneurysms Treated by Endovascular Parent Vessel Occlusion

2:43 PM Posted by Dr Subhash Kumar, MBBS, MD, DM


Long-Term Clinical and Imaging Follow-Up of Complex Intracranial Aneurysms Treated by Endovascular Parent Vessel Occlusion

  1. R.A. Willinsky
+Author Affiliations
  1. From the Department of Neurosurgery, Neurovascular & Stroke Programs (C.C.M.), Yale University School of Medicine, New Haven, Connecticut; Division of Neuroradiology, Department of Medical Imaging (Z.K., K.G.t.B., R.A.W.), Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada.
  1. Please address correspondence to Charles C. Matouk, Department of Neurosurgery, Neurovascular & Stroke Programs, Yale University School of Medicine, 333 Cedar St, TMP402, New Haven, CT, 06510; e-mail: charles.matouk@yale.edu

Abstract

BACKGROUND AND PURPOSE: Flow-diverting stents are increasingly being used for the treatment of complex intracranial aneurysms, but the indications for their use in lieu of traditional endovascular PVO have yet to be precisely defined. The purpose of this study was to review the clinical and imaging outcomes of patients with intracranial aneurysms treated by PVO.
MATERIALS AND METHODS: A total of 28 patients with intracranial aneurysms, treated by PVO between July 1992 and December 2009, were reviewed. Aneurysms arising from peripheral arteries were excluded. Clinical and imaging data were retrospectively analyzed from a prospectively maintained data base.
RESULTS: There were 28 patients with 28 aneurysms treated by PVO. Aneurysms of the anterior circulation presenting with mass effect (n = 11) or discovered incidentally (n = 1), and dissecting-type VB aneurysms presenting with subarachnoid hemorrhage (n = 6) faired the best with high obliteration rates (83.3% and 83.6%, respectively) and no permanent major ischemic complications. In contrast, VB aneurysms presenting with mass effect (n = 7) demonstrated the lowest obliteration rate (57.1%), the highest rate of permanent major ischemic complications (28.6%), and a high mortality rate (28.6%).
CONCLUSIONS: PVO is a safe and effective treatment for complex intracranial aneurysms of the carotid artery and dissecting-type VB aneurysms presenting with SAH. In contrast, PVO for aneurysms of the VB circulation presenting with mass effect is less efficacious and associated with significant morbidity and mortality. It is hoped that flow diverters may represent a better treatment technique for these most difficult-to-treat lesions.

Abbreviations

BTO
 
balloon test occlusion
 
ECIC
 
extracranial-intracranial
 
PCA
 
posterior cerebral artery
 
PVO
 
parent vessel occlusion
 
VA
 
vertebral artery
 
VB
 
vertebrobasilar
http://www.ajnr.org/content/early/2012/05/03/ajnr.A3079.abstract
Published online before print May 3, 2012,  doi: 10.3174/ajnr.A3079


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