Endovascular Treatment of Ruptured Brain AVMs in the Acute Phase of Hemorrhage [INTERVENTIONAL]
Endovascular Treatment of Ruptured Brain AVMs in the Acute Phase of Hemorrhage [INTERVENTIONAL]
Patients with ruptured brain AVMs are at considerable risk of repeat hemorrhage, particularly when associated intranidal or flow-related aneurysms are present. There is controversy about the timing of diagnosis and treatment of patients with hemorrhagic stroke. We present our results of endovascular treatment of ruptured AVMs in the acute phase.
MATERIALS AND METHODS:Between January 2008 and March 2011, 23 patients (16 men, 7 women; mean age 42 years) with AVM-related hemorrhagic stroke were treated with endovascular techniques within 10 days of the ictus. There were 10 micro-AVMs (< 1 cm) and 1 single-hole pial fistula. In 9 patients, an intranidal or flow-related aneurysm was the likely cause of hemorrhage.
RESULTS:Complete obliteration of the AVM with Onyx was achieved in 13 of 23 patients (57%). Eight of the 13 AVMs were micro-AVMs and 3 had an intranidal aneurysm. Partial obliteration of the AVM was achieved in 10 of 23 patients (43%). In 6 of these 10 patients, an intranidal (n = 1) or flow-related aneurysm (n = 5) was obliterated with Onyx or coils. There were no complications of treatment. During a mean follow-up of 21 months in 22 surviving patients, no repeat hemorrhage occurred.
CONCLUSIONS:Endovascular treatment with Onyx in the acute phase cured most ruptured AVMs. All 9 AVM-associated aneurysms that were considered the source of hemorrhage could be excluded from the circulation. In patients with AVM-related hemorrhagic stroke, prompt angiographic diagnosis and treatment may improve prognosis by reducing repeat hemorrhage rate.
http://www.ajnr.org/content/early/2012/01/26/ajnr.A2995.abstract
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Multimodal Reperfusion Therapy for Large Hemispheric Infarcts in Octogenarians: Is Good Outcome a Realistic Goal?
Multimodal Reperfusion Therapy for Large Hemispheric Infarcts in Octogenarians: Is Good Outcome a Realistic Goal?
Abstract
BACKGROUND AND PURPOSE: MMRT may be beneficial in a subset of patients with large hemispheric stroke who cannot be treated with systemic thrombolysis. Because most previous studies only included relatively young patients, the outcome of very old patients given MMRT remains unknown.
MATERIALS AND METHODS: Consecutive patients with large hemispheric stroke treated with MMRT and admitted to intensive care were included. We compared neurologic and functional outcomes between patients younger and older than 80 years.
RESULTS: We included 14 patients older than 80 years and compared them with 66 patients who were younger than 80. Cerebrovascular risk factor profile, admission NIHSS scores, stroke etiology and pathogenesis, and procedure-related variables did not differ between the groups except for a higher prevalence of smoking in younger patients. Excellent target vessel recanalization (Thrombolysis in Myocardial Infarction score of 3) and good outcome at 90 days (modified Rankin Score ≤2) were more common in younger patients (45% versus 14%, P = .047, and 41% versus 0%, P = .008, respectively). In contrast, mortality rates were higher in octogenarians (43% versus 17%, respectively).
CONCLUSIONS: In this study, very old patients had higher chances of mortality and a very low probability of achieving functional independence even after MMRT. Further prospective studies are needed to examine the futility of MMRT in the very old.
Abbreviations
- GP IIb/IIIa
- glycoprotein IIb/IIIa
- IA
- intra-arterial
- MMRT
- multimodal reperfusion therapy
- TIMI
- Thrombolysis in Myocardial Infarction
- TOAST
- Trial of ORG 10172 in Acute Stroke
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Interobserver Reliability of Baseline Noncontrast CT Alberta Stroke Program Early CT Score for Intra-Arterial Stroke Treatment Selection [BRAIN]
- A.C. Gupta,
- P.W. Schaefer,
- Z.A. Chaudhry,
- T.M. Leslie-Mazwi,
- R.V. Chandra,
- R.G. González,
- J.A. Hirsch and
- A.J. Yoo
Early ischemic changes on pretreatment NCCT quantified using ASPECTS have been demonstrated to predict outcomes after IAT. We sought to determine the interobserver reliability of ASPECTS for patients with AIS with PAO and to determine whether pretreatment ASPECTS dichotomized at 7 would demonstrate at least substantial agreement.
MATERIALS AND METHODS:From our prospective IAT data base, we identified consecutive patients with anterior circulation PAO who underwent IAT over a 6-year period. Only those with an evaluable pretreatment NCCT were included. ASPECTS was graded independently by 2 experienced readers. Interrater agreement was assessed for total ASPECTS, dichotomized ASPECTS (≤7 versus >7), and each ASPECTS region. Statistical analysis included determination of Cohen coefficients and concordance correlation coefficients. PABAK coefficients were also calculated.
RESULTS:One hundred fifty-five patients met our study criteria. Median pretreatment ASPECTS was 8 (interquartile range 7–9). Interrater agreement for total ASPECTS was substantial (concordance correlation coefficient = 0.77). The mean ASPECTS difference between readers was 0.2 (95% confidence interval, –2.8 to 2.4). For dichotomized ASPECTS, there was a 76.8% (119/155) observed rate of agreement, with a moderate = 0.53 (PABAK = 0.54). By region, agreement was worst in the internal capsule and the cortical areas, ranging from fair to moderate. After adjusting for prevalence and bias, agreement improved to substantial or near perfect in most regions.
CONCLUSIONS:Interobserver reliability is substantial for total ASPECTS but is only moderate for ASPECTS dichotomized at 7. This may limit the utility of dichotomized ASPECTS for IAT selection.
http://www.ajnr.org/content/early/2012/02/09/ajnr.A2942.abstract
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Recanalization with Wingspan Stent for Acute Middle Cerebral Artery Occlusion in Failure or Contraindication to Intravenous Thrombolysis: A Feasibility Study [INTERVENTIONAL]
Recanalization with the Wingspan stent, which can be deployed rapidly and safely, is an option for treating acute ischemic stroke when intravenous thrombolysis has failed or is contraindicated. This study was performed to evaluate feasibility, efficacy, and safety of recanalization for acute middle cerebral artery occlusion using the Wingspan stent.
MATERIALS AND METHODS:We collected 10 patients with acute MCA occlusion in whom recanalization was not achieved with a standard intravenous thrombolysis, or who were ineligible for intravenous thrombolysis, or who presented after 3 hours of symptom onset and in whom the stent placement could be completed within 8 hours from symptom onset. We analyzed angiographic and clinical results.
RESULTS:Successful recanalization with the Wingspan stent was achieved in all patients. The mean NIHSS score on admission was 12.7 points (range 4–21). The occlusion sites were located in the 1st segment (n = 7; 2 left, 5 right) and 2nd segment (n = 3, all right) of the MCA. The mean time interval from stroke symptom onset to stent placement was 344.8 ± 76.3 minutes. No intracranial hemorrhage, vessel perforations, or dissections occurred in any patient. Nine patients improved on the NIHSS at 7 days. One patient did not have a change in the NIHSS score, even though the occluded artery was completely recanalized. At 7 days, the NIHSS score of all patients was 4.4 ± 4.7 (median 4, range 0–13). At discharge, an mRS of ≤3 was achieved in all patients and an mRS of ≤2 was achieved in 7 patients (70%).
CONCLUSIONS:This small case series demonstrates the feasibility of using the Wingspan stent safely and effectively for MCA occlusions when standard treatments are ineffective or not available.
http://www.ajnr.org/content/early/2012/02/09/ajnr.A2996.abstract
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Incomplete mechanical recanalization of middle cerebral artery occlusions facilitates endogenous recanalization within 5 h
Incomplete mechanical recanalization of middle cerebral artery occlusions facilitates endogenous recanalization within 5 h
Background and purpose
Successful revascularization can often improve functional outcome after large intracranial arterial occlusions. However, incomplete or unsuccessful recanalization is often the end result after attempted mechanical thrombectomy. A study was undertaken to determine whether partial recanalization of proximal isolated middle cerebral artery (MCA) occlusions facilitates endogenous thrombolysis and spontaneous recanalization.
MethodsWe retrospectively analyzed consecutive patients with acute ischemic stroke undergoing mechanical thrombectomy using the Merci Retriever System for occlusions involving any portion of the M1 segment of the MCA. Only those patients with a residual obstruction of the proximal MCA segments were included. The rates of facilitated endogenous recanalization (FER5) by imaging within the 5 h following intervention were compared in patients with partial proximal recanalization and those in whom recanalization was unsuccessful.
ResultsForty-two patients were included in the analysis. Twenty-six patients had good recanalization of the proximal aspect of the target lesion with an arterial occlusive lesion score of 2 or 3 but a residual partial or total occlusion of the MCA, while 16 patients failed to recanalize any portion of the target occlusion. Twelve patients (46%) in the first group and only one (5.9%) in the second group had facilitated endogenous recanalization on interval imaging 5 h after intervention (OR 12.9, 95% CI 1.5 to 112.2). Nine patients with proximal recanalization had good clinical outcomes at discharge (mRS ≤2) compared with none without recanalization (p=0.01), but FER did not have a relationship with clinical outcome.
ConclusionsDespite initially incomplete proximal mechanical thrombectomy, nearly half of all patients with residual M1 occlusions will undergo further endogenous recanalization within the subsequent 5 h.
http://jnis.bmj.com/content/early/2012/02/06/neurintsurg-2011-010207.short
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Routine pre-procedure laboratory testing for patients undergoing outpatient cerebral angiography is not indicated
Cerebral angiography is a routine low-risk procedure. Laboratory testing is performed in almost all patients. Some testing may be warranted in selected patients but can also result in delays in performing the procedure.
PurposeTo determine if routine pre-procedure testing for outpatient cerebral angiography is necessary.
Methods447 patients who underwent outpatient cerebral angiography were reviewed. The tests were evaluated for any abnormality, correlation of the abnormality with underlying diseases and for any impact that these tests may have on the safety of the procedure. Only tests performed at our institution were analyzed. All instances of any hospital/physician visit related to the procedure were recorded.
ResultsA low hemoglobin, hematocrit and platelet count was seen in 3.5%, 1.8% and 0.1% of patients, respectively. These were marginally outside the reference range and not sufficiently abnormal to indicate underlying disease or to affect the procedure. An elevated prothrombin time/international normalized ratio was seen in 4.5% of patients and this was associated with warfarin use (p<0.0001). About 15% of the patients had a disturbance in renal function. An elevated creatinine was associated with diabetes (OR 3.2, 95% CI 1.8 to 5.7, p=0.0001) and hypertension (OR 4.4, 95% CI 2.1 to 9.2, p<0.0001). Cerebral angiography was performed on these patients with appropriate renal protective measures and no cases of acute renal failure secondary to contrast administration were documented.
ConclusionThe incidence of abnormal testing in patients undergoing outpatient cerebral angiography is very low. These results and evidence in the literature suggest that the majority of patients undergoing cerebral angiography do not require any pre-procedure testing. Assessment of renal function using the estimated glomerular filtration rate in high-risk patients only is, however, warranted.
http://jnis.bmj.com/content/early/2012/02/08/neurintsurg-2011-010200.short
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