Risk Profile of Intracranial Aneurysms: Rupture Rate Is Not Constant After Formation [Original Contributions; Clinical Sciences]

8:06 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Wonderful article
this was always suspected or rather known that small aneurysms do rupture but the prospective trials could not show this. Sato et al have now come with this article and proven statistically that some aneurysms form and rupture soon after while others remain stable and do not rupture for long.


: Background and Purpose—

Management of asymptomatic unruptured intracranial aneurysms remains controversial, and recent prospective follow-up studies showed that the rupture rate of small aneurysms is very low. These results are inconsistent with the finding that the majority of ruptured aneurysms in patients with subarachnoid hemorrhage are small.



Methods—

A Markov model was constructed to simulate the natural history of intracranial aneurysms. All epidemiological and statistical data obtained from the Portal Site of Official Statistics of Japan (e-Stat) were adjusted to the standardized age distribution. From the selected data of aneurysm formation, the prevalence of unruptured aneurysms was estimated as 1.45% and the incidence of subarachnoid hemorrhage calculated to be 19.7/100 000/year in the whole standardized population.



Results—

The function for rupture rate constant with time was first analyzed. Selected values for annual rupture rates of 0.3%, 0.5%, 0.7%, and 1.0% showed inconsistencies in the relationship between the prevalence of unruptured aneurysm and the incidence of subarachnoid hemorrhage. Next, the function for a short period of high risk followed by a long period of low risk was considered. Annual rupture rates of 0.5%, 0.7%, and 1.0% indicated epidemiological compatibility with additional early rupture rates of 20%, 15%, and 10%, respectively.



Conclusions—

This study suggests that some aneurysms bleed shortly after formation and thus are rarely detected as unruptured aneurysms. Most aneurysms without early rupture remain stable for the remainder of life through some healing process, and prophylactic treatment for incidentally identified small unruptured aneurysms has no rationale.


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Neurogenic pulmonary edema after rupture of intracranial aneurysm during endovascular coiling

10:58 AM Posted by Dr Subhash Kumar, MBBS, MD, DM

Neurogenic pulmonary edema (NPE) is a well-known entity, occurs after acute severe insult to the central nervous system. It has been described in relation to different clinical scenario. However, NPE has rarely been mentioned after endovascular coiling of intracranial aneurysms.
In this recently published article of mine along with my anesthsia colleagues, the clinical course of a patient who developed NPE after aneurysmal rupture during endovascular surgery has been reported. This case highlights the predisposition of minimally invasive procedures like endovascular coiling to life-threatening complications such as NPE.
However, we must know that such cases occur once a blue moon and are more of a tool of nature to bring down to earth the high-flying physicians.
Click to read full article on pubmed central website
Neurogenic Pulmonary Edema After Rupture of Intracranial Aneurysm During EnDoVascular Coiling


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Accuracy of On-Call Resident Interpretation of CT Angiography for Intracrani...

7:19 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Excellent article...it is oft noted but no one bothered about it...its time some one looked into the matter.
While radiology residents are pretty good in reporting in general, they lack the skills in vascular imaging and neuroradiology in general.


via American Journal of Roentgenology current issue by Hochberg, A. R., Rojas, R., Thomas, A. J., Reddy, A. S., Bhadelia, R. A. on 11/22/11

OBJECTIVE. The purpose of this article is to evaluate the accuracy of preliminary on-call radiology resident interpretation of CT angiography (CTA) compared with digital subtraction angiography (DSA) in detecting cerebral aneurysms in subarachnoid hemorrhage (SAH).
MATERIALS AND METHODS. A retrospective review compared resident interpretations of head CTA performed after hours for SAH to the results of DSA. The sensitivity and specificity of resident interpretations were classified on a per-patient and per-aneurysm basis. The accuracy of resident interpretations was also determined according to aneurysm location and number.
RESULTS. Between January 2007 and December 2009, 83 patients with SAH underwent both CTA and DSA. DSA documented an aneurysm in 53 of 83 patients. Per patient, residents identified at least one aneurysm in 46 of 53 patients (87%). Per aneurysm, resident sensitivity and specificity for detecting aneurysms of any size were 62% and 91%, respectively, which improved for aneurysms 3 mm or larger to 73% and 97%, respectively. The posterior communicating and intracranial internal carotid arteries were resident "blind spots," with aneurysms 3 mm or larger detected with sensitivities of 33% and 50%, respectively. In contrast, anterior communicating artery aneurysms were correctly identified 95% of the time. In only 35% of cases with multiple aneurysms did residents correctly identify more than one aneurysm.
CONCLUSION. The sensitivity of on-call resident interpretation of CTA for aneurysms in SAH is lower than expected, with a potential for delay in diagnosis and management in a small number of patients. Focused training to carefully review apparent blind spots and the frequency of multiple aneurysms may reduce inaccuracies.


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Interventional Stroke Therapies in the Elderly: Are We Helping?

6:59 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 Zeevi, N., Kuchel, G. A., Lee, N. S., Staff, I., McCullough, L. D.

BACKGROUND AND PURPOSE:
It is unclear whether endovascular therapies for the treatment of AIS are being offered or are safe in older adults. The use and safety of endovascular interventions in patients older than 75 years of age were assessed.
MATERIALS AND METHODS:
A retrospective review of patients with AIS 75 years or older (n = 37/1064) was compared with a younger cohort (n = 70/1190) by using an established data base. Admission and discharge NIHSS scores, rates of endovascular treatment, SICH, in-hospital mortality, and the mBI were assessed.
RESULTS:
Rates of endovascular treatments were significantly lower in older patients (5.9% in the younger-than-75-year versus 3.5% in the older-than-75-year cohort, P = .007). Stroke severity as measured by the NIHSS score was equivalent in the 2 age groups. The mBI at 12 months was worse in the older patients (mild or no disability in 52% of the younger-than-75-year and 22% in the 75-year-or-older cohort, P = .006). Older patients had higher rates of SICH (9% in younger-than-75-year versus 24% in the 75-year-or-older group, P = .04) and in-hospital mortality (26% in younger-than-75-year versus 46% in the 75-year-or-older group, P = .05).
CONCLUSIONS:
Patients older than 75 years of age were less likely to receive endovascular treatments. Older patients had higher rates of SICH, disability, and mortality. Prospective randomized trials are needed to determine the criteria for selecting patients most likely to benefit from acute endovascular therapies.


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Pediatric Intracranial Aneurysms: New and Enlarging Aneurysms after Index Aneurysm Treatment or Observation [PEDIATRICS]

4:18 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Pediatric Intracranial Aneurysms: New and Enlarging Aneurysms after Index Aneurysm Treatment or Observation

BACKGROUND AND PURPOSE:

Children with brain aneurysms may be at higher risk than adults to develop new or enlarging aneurysms in a relatively short time. We sought to identify comorbidities and angiographic features in children that predict new aneurysm formation or enlargement of untreated aneurysms.

MATERIALS AND METHODS:

Retrospective analysis of the University of California–San Francisco Pediatric Aneurysm Cohort data base including medical records and imaging studies was performed.

RESULTS:

Of 83 patients harboring 114 intracranial aneurysms not associated with brain arteriovenous malformations or intracranial arteriovenous fistulas, 9 (8.4%) developed new or enlarging brain aneurysms an average of 4.2 years after initial presentation. Comorbidities that may be related to aneurysm formation were significantly higher in patients who developed new aneurysms (89%) as opposed to patients who did not develop new or enlarging aneurysms (41%; RR, 9.5; 95% CI, 1.9%–48%; P = .0099). Patients with multiple aneurysms at initial presentation were more likely than patients with a single aneurysm at presentation to develop a new or enlarging aneurysm (RR, 6.2; 95% CI, 2.1%–185; P = .0058). Patients who initially presented with at least 1 fusiform aneurysm were more likely to develop a new or enlarging aneurysm than patients who did not present with a fusiform aneurysm (RR, 22; 95% CI, 3.6%–68%; P = .00050). Index aneurysm treatment with parent artery occlusion also was associated with higher risk of new aneurysm formation (RR, 4.2; 95% CI, 1.3%–13%; P = .024). New aneurysms did not necessarily arise near index aneurysms. The only fatality in the series was due to subarachnoid hemorrhage from a new posterior circulation aneurysm arising 20 months after index anterior circulation aneurysm treatment in an immunosuppressed patient.

CONCLUSIONS:

Patients who presented with a fusiform aneurysm had a significantly greater incidence of developing a new aneurysm or enlargement of an index aneurysm than did those who presented with a saccular aneurysm. In our patient cohort, 8 of the 9 children who eventually developed new or enlarging brain aneurysms initially presented with fusiform aneurysm morphology. Other comorbidities or multiple aneurysms were also common in these patients at initial presentation.


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Cerebral Perfusion Long Term after Therapeutic Occlusion of the Internal Carotid Artery in Patients Who Tolerated Angiographic Balloon Test Occlusion

4:16 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Cerebral Perfusion Long Term after Therapeutic Occlusion of the Internal Carotid Artery in Patients Who Tolerated Angiographic Balloon Test Occlusion

Gevers, S., Heijtel, D., Ferns, S. P., van Ooij, P., van Rooij, W. J., van Osch, M. J., van den Berg, R., Nederveen, A. J., Majoie, C. B.

BACKGROUND AND PURPOSE:

Therapeutic carotid occlusion is an established technique for treatment of large and giant aneurysms of the ICA, in patients with synchronous venous filling on angiography during BTO. Concern remains that hemodynamic alterations after permanent occlusion will predispose the patient to new ischemic injury in the ipsilateral hemisphere. The purpose of this study was to assess whether BTO with synchronous venous filling is associated with normal CBF long term after carotid sacrifice.

MATERIALS AND METHODS:

Eleven patients were included (all women; mean age, 50.5 years; mean follow-up, 38.5 months). ASL with single and multiple TIs was used to assess CBF and its temporal characteristics. Selective ASL was used to assess actual territorial contribution of the ICA and BA. Collateral flow via the AcomA or PcomA or both was determined by time-resolved 3D PCMR. Paired t tests were used to compare CBF and timing parameters between hemispheres.

RESULTS:

Absolute CBF values were within the normal range. There was no significant CBF difference between hemispheres ipsilateral and contralateral to carotid sacrifice (49.4 ± 11.2 versus 50.1 ± 10.1 mL/100 g/min). Arterial arrival time and trailing edge time were significantly prolonged on the occlusion side (816 ± 119 ms versus 741 ± 103 ms, P = .001; and 1765 ± 179 ms versus 1646 ± 190 ms, P < .001). Two patients had collateral flow through the AcomA only and were found to have increased timing parameters compared with 9 patients with mixed collateral flow through both the AcomA and PcomA.

CONCLUSIONS:

In this small study, patients with synchronous venous filling during BTO had normal CBF long term after therapeutic ICA occlusion.


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Stent assisted coiling of wide neck basilar tip aneurysm

2:56 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

This is the case of a middle aged patient with Fisher grade 3, Hunt and Hess grade 2 subarachnoid haemorrhage with a ruptured basilar tip aneurysm. The aneurysm was moderate sized, with a wide neck ~ 7 mm involving both the proximal p1 PCA segments (left more than right), and directed posterosuperiorly. The  Pcoms were seen although not very prominent.

An Enterprise 5.5 x 22 mm stent was passed via a Prowler Select Plus microcatheter across the aneurysm neck into the left PCA with trailing portion kept in the basilar artery. A SL 10 microcatheter was then navigated and placed in the aneurysm fundus. The stent was partially opened (JAILING technique) and coiling done. Good packing of the aneurysm was achieved. Then the stent was fully deployed and left in situ.

The patient had been prepared with 300 mg Aspirin and 300 mg Clopidogrel prior to the procedure and given 5000 U heparin bolus after sheath placement. A single femoral puncture had been done with 6F sheath placement and a 6F Envoy used as guide catheter. A double Y Tuohy Borst hemostatic adapter was used to pass the stent and coil noth through the same guide catheter.

The patient had an uneventful recovery and was discharged in stable condition.

She was advised to have Aspirin 150 mg and Clopidogrel 75 mg once daily for next three months and then Aspirin 150 mg for life.

image

Fig 1. Frontal and Lateral views of LVA injection

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Fig 2. 3D DSA images of LVA injection

image

Fig 3. Stent placement in the left PCA across the aneurysm neck

image

Fig 4. Coiling of the aneurysm

image

Fig 5. The deployed stent and fully coiled aneurysm

image

Fig 6. Pre and post procedure comparative angiograms


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Regional Leptomeningeal Score on CT Angiography Predicts Clinical and Imaging Outcomes in Patients with Acute Anterior Circulation Occlusions

1:44 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

The presence/absence, degree and the speed of development of collateral flow in acute stroke strongly correlate with patient outcome. So far, DSA was the only reliable way to assess the colateral circulation. Of late, however, with the improved CT angiogram technology, excellent visualisation of teh medium sized vessels is possible and the cortical/leptomeningeal vessels ca be reliably seen. This has led to visual  assessment of the degree of the leptomeningeal collateral.
In this article from Alberta, an objective scoring system with clincal correlation has been published and is welcome. It should pave the path for better non-invasive assessment of the patient.
 Link to the article in journal's website


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Case examples in the this blog

5:47 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 Spine
  1. An Unusual case of hematomyelia
Aneurysm
  1. Intracranial HIV vasculopathy with multiple aneurysms
  2. Embolisation of Dissecting basilar artery aneurysm
  3. Stent induced spasm during coiling of a vertebral artery dissecting aneurysm
  4. Post traumatic ophthalmic artery pseudoaneurysm
  5. Spontaneous occlusion of posterior cerebral artery aneurysm
  6. Fenestrated posterior inferior cerebellar artery with concomitant vertebro-basilar junction fenestration and vertebral artery aneurysm
  7. Basilar artery dissecting aneurysm treated by flow diversion with Enterprise stent only
  8. Flow diversion treatment of internal carotid artery blister aneurysm with Enterprise stent
  9. Internal carotid artery perforation by microguidewire during Acom artery aneurysm coiling
AVM


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Higher Incidence of In-Hospital Complications in Patients With Clipped Versus Coiled Ruptured Intracranial Aneurysms

4:42 PM Posted by Dr Subhash Kumar, MBBS, MD, DM


An excellent paper from Toronto. the authors have examined the  Registry of the Canadian Stroke Network to evaluate 931 patients and found significantly increased complication rates, mortality, increased hospital stay in patients undergoing clipping as opposed to coiling.

Link to the article in the journal website

Higher Incidence of In-Hospital Complications in Patients With Clipped Versus Coiled Ruptured Intracranial Aneurysms

  1. Mervyn D.I. Vergouwen, MD, PhD; 
  2. Jiming Fang, PhD;
  3. Leanne K. Casaubon, MD, MSc, FRCPC; 
  4. Melissa Stamplecoski;
  5. Annette Robertson, RN, RDCS; 
  6. Moira K. Kapral, MD, MSc, FRCPC;
  7. Frank L. Silver, MD, FRCPC on behalf of the Investigators of the Registry of the Canadian Stroke Network
From the Department of Medicine, Division of Neurology (M.D.I.V., L.K.C., F.L.S.) and Division of General Internal Medicine and Clinical Epidemiology and Women's Health Program (M.K.K.), University Health Network, University of Toronto, Toronto, Canada; Utrecht Stroke Center, Department of Neurology and Neurosurgery (M.D.I.V.), University Medical Center Utrecht, Utrecht, the Netherlands; the Department of Health Policy, Management and Evaluation (M.K.K.), University of Toronto, Toronto, Canada; the Institute for Clinical Evaluative Sciences (J.F., M.S., A.R., M.K.K., F.L.S.), Toronto, Canada; and the Canadian Stroke Network (M.K.K., F.L.S.).
  1. Correspondence to Mervyn D.I. Vergouwen, MD, PhD, Utrecht Stroke Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands. E-mailm.d.i.vergouwen@umcutrecht.nl

Abstract

Background and Purpose—After aneurysmal subarachnoid hemorrhage (SAH), patients with clipped aneurysms have a higher incidence of neurocognitive deficits and seizures compared with patients with coiled aneurysms. It remains unknown if patients with clipped aneurysms also have a higher incidence of other in-hospital complications.
Methods—We used data from the Registry of the Canadian Stroke Network on consecutive patients admitted to hospital with aneurysmal SAH. Patients who died within 2 days after admission were excluded. Baseline characteristics, incidence of various in-hospital complications within 30 days after admission, length of stay, poor functional outcome (modified Rankin Scale score at discharge of ≥3), and mortality were compared between patients with clipped versus coiled aneurysms.
Results—Of the 931 patients, 548 (59%) were clipped and 383 (41%) coiled. Baseline characteristics were similar. Compared with patients with coiled aneurysms, patients with clipped aneurysms had a higher incidence of in-hospital complications (37.2% versus 24.5% of patients; P<0.0001), poor functional outcome at discharge (69.4% versus 51.4%; P<0.0001), mortality (at discharge: 14.6% versus 9.1%; P=0.01), and a longer length of stay (17 [interquartile range, 11 to 29] versus 13 [interquartile range, 7 to 22] days; P<0.0001). Higher incidences were observed for urinary tract infection (P=0.02), pneumonia (P=0.01), cardiac/respiratory arrest (P=0.007), seizure (P=0.01), and decubitus ulcer (P=0.02). Urinary tract infection, pneumonia, cardiac/respiratory arrest, and seizure were independent predictors of poor functional outcome.
Conclusions—Patients with clipped aneurysms have a higher incidence of in-hospital complications than patients with coiled aneurysms, which attributes to a higher risk of poor functional outcome and death and an increased length of stay.


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