ABSTRACT PURPOSE To study the effect of transfer status on endovascularly treated AIS patients&am... more ABSTRACT PURPOSE To study the effect of transfer status on endovascularly treated AIS patients' outcomes. METHOD AND MATERIALS We retrospectively analyzed consecutive anterior circulation AIS patients that underwent IAT at 4 institutions from 2006-2011. We excluded patients selected using perfusion imaging. Patient demographics, medical risk factors, presentations, technical, and clinical (NIHSS and mRS scores) outcomes, complications, and mortality were studied. Symptom-onset, groin puncture, and end-of-procedure times were recorded. THRIVE scores were calculated. Successful recanalization was defined as TIC I≥2b. Good functional outcome was defined as mRS 0-2 at 90 days. Patients were categorized into those who were transferred from outside institutions and those who presented directly to the CSCs. RESULTS 116 patients were studied. 68 (58.6%) were transferred from outside institutions. Transfers and nontransfers were similar in THRIVE scores (p=0.300), median symptom-onset to groin puncture times (306 vs. 315 minutes; p=0.572), successful recanalization (p=0.574), and symptomatic IC H (13.2 vs. 10.4, p=0.776), but differed by age (59 vs. 69 years;p=0.002), prior stroke (3% vs. 22%,p=0.002), cardiac history (17.9 vs. 36.6%,p=0.040), baseline NIHSS (20 vs. 17, p=0.005), and location of occlusion (45.6% vs. 22.9% IC A, p=0.012). Transfer patients had significantly worse outcomes at 90 days (mRS 0-2: 16.2% vs. 60.4%,p<0.001). In multivariate analysis, transfer status was an independent predictor of poor functional outcome (adj. OR 0.05, 0.011-0.222), adjusting for relevant covariates. CONCLUSION Transferred AIS patients have worse functional outcomes at 90 days than non-transfers, independent of baseline risk factors, stroke severity, time to IAT, and procedural success/complications. Further investigation should focus on residual factors that may contribute to our findings such as baseline/final infarct volumes, pre-morbid functional status, and post-stroke care. CLINICAL RELEVANCE/APPLICATION Access to intra-arterial therapy (IAT) for acute ischemic stroke (AIS) is limited to comprehensive stroke centers (CSCs) with timely access deemed critical for success. Inter-hospital transfers rep
PURPOSE Intracranial atherosclerotic disease (ICAD) is associated with significant morbidity. Sur... more PURPOSE Intracranial atherosclerotic disease (ICAD) is associated with significant morbidity. Surgical or endovascular intervention has been relegated to patients who fail medical management; but even with optimum management, the risk of recurrent strokes exists. There is no risk stratification scheme to identify this susceptible population prior to presenting with refractory strokes. We studied the differences in quantitative cerebral blood flow (qCBF) and volume (qCBV) measurements between vascular territories with and without acute infarcts in patients with advanced ICAD. METHOD AND MATERIALS We retrospectively identified 8 patients (4 Male, 4 Female; 66 +/- 14 years old) with moderate to severe intracranial stenoses (>50%) as identified with MRA within the supraclinoid ICA, ACA, MCA or PCA that had a correlative DSC-MR PWI scan at time of presentation. Vascular territories were divided into subgroups containing acute infarcts on MR DWI versus no infarcts. After the imaging se...
PURPOSE To report on a case of cranial venous outflow obstruction and intracranial venous hyperte... more PURPOSE To report on a case of cranial venous outflow obstruction and intracranial venous hypertension treated with right sigmoid sinus stent placement and angioplasty. CASE REPORT The patient was a 6-year-old male who presented with macrocephaly, prominent facial and scalp veins, limitation of strenuous activity and speech delay. On physical examination, he had a head circumference greater than 95th percentile, slight left eye extropia, bilateral optic disk pallor and decreased visual acuity. Neurologic examination was otherwise normal. One month prior to presentation, he underwent a left parietal and frontal burhole craniostomy to drain chronic bilateral subdural hematoma which was detected on his brain CT scan. The fluid collection was stable in size, with no midline shift or clinical symptoms. In our institution, a brain CT/CT angiogram was performed. Imaging findings included mild to moderate diffuse cerebral atrophy, bilateral subdural fluid collections (larger on the left) wi...
Objective: The objective was to evaluate the efficacy of percutaneous sacroplasty using both comp... more Objective: The objective was to evaluate the efficacy of percutaneous sacroplasty using both computed tomographic (CT) and fluoroscopic guidance in treatment of sacral insufficiency fractures (SIFs) with respect to pain relief and overall functional capacity. Materials and Methods: After obtaining approval from the institution’s review board, we retrospectively studied eleven consecutive patients treated by percutaneous sacroplasty in a single center from 2003 to 2008. All included patients had back pain causing restriction of activities of daily living. Using a numerical rating scale (zero (“no pain”) to ten (“worst pain imaginable”), pain assessment was performed before and after the procedure to score their pain. Results: Eleven patients underwent sacroplasty for SIFs, with a female to male ratio of 10:1. All patients presented with back pain and limited activities of daily living (ADLs). Imaging studies included CT spine (n=7), MRI spine (n=5) and whole body bone scan (n=5), wit...
Postpartum cervicocephalic artery dissection (pp-CAD) is a rare and poorly understood condition. ... more Postpartum cervicocephalic artery dissection (pp-CAD) is a rare and poorly understood condition. To our knowledge, only 21 cases have been reported. Reversible cerebral segmental vasoconstriction was first described by Call and Fleming in 1988, and its association with pp-CAD has only been reported in three cases. However, in those cases it is unclear whether the pp-CAD may have been caused by straining during labor and therefore merely coincidental to the intracranial arteriopathy. We report a 42-year-old right handed African-American woman who developed the syndrome of pp-CAD (headaches, trace sub-arachnoid hemorrhage and diffuse cerebral arteriopathy on angiogram) 2 weeks after delivery. In this unique case, the patient had fortuitously undergone an MR study twice over a 4-day period which included the carotid bifurcations. During that time the patient was an inpatient, on bed rest and subject to continuous cardiac monitoring. The interval studies documented a true spontaneous right internal carotid artery dissection occurring without obvious cause. The patient had noted moderate right neck pain developing between the two MR studies but experienced no neurological deficits. Subsequent conventional angiography confirmed the presence of postpartum cerebral arteriopathy and the cervical dissection. The patient was managed conservatively with antiplatelet medication and had an otherwise uneventful course. We hypothesize whether transient arterial wall abnormalities, postpartum hormonal changes or subtle connective tissue aberrations play a similar role in the pathogenesis of these two associated conditions.Image A: Angiogram of the right carotid bifurcation demonstrates a focal stenosis (arrow) of the right ICA distal to the bulb due to an incompletely thrombosed dissection with partial opacification of the pseudo-lumen origin (arrowhead). Image B: Cerebral angiogram shows multifocal arteriopathic beading in all territories (arrows).
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, Jan 8, 2015
We describe the novel use of a double lumen balloon catheter for venous sinus thrombolysis and ve... more We describe the novel use of a double lumen balloon catheter for venous sinus thrombolysis and venoplasty. Cerebral venous sinus thrombosis is a rare disease that is usually treated with medical anticoagulation. In certain refractory cases, surgical or endovascular thrombolysis and thrombectomy may be required. A 48year-old man on anticoagulation for cerebral venous sinus thrombosis presented with nausea, vomiting and worsening hemiparesis. The patient underwent endovascular venous sinus thrombolysis and venoplasty with continuous in situ tissue plasminogen activator (tPA) infusion over 48hours. This novel approach to the endovascular treatment of venous sinus thrombosis, including the use of a double lumen balloon was advantageous, as it allowed direct infusion of tPA through the balloon catheter without having to exchange the balloon for a microcatheter.
We describe the case of a 28-year-old obtunded woman who presented with bilateral anterior pariet... more We describe the case of a 28-year-old obtunded woman who presented with bilateral anterior parietal lobe cortical hemorrhages associated with thrombosis of the superior sagittal sinus, both transverse and sigmoid sinuses, and multiple cortical veins draining into the sagittal sinus. Initial heparin therapy was not effective. A combination of AngioJet rheolytic catheter thrombectomy, balloon angioplasty, and continuous direct superior sagittal sinus recombinant tissue plasminogen activator infusion led to venous recanalization with a successful clinical outcome, without worsening of the preexisting intracranial hemorrhages.
The authors describe what is, to their knowledge, the first reported case of the anomalous origin... more The authors describe what is, to their knowledge, the first reported case of the anomalous origin of an internal carotid artery from the pulmonary artery. An otherwise asymptomatic 6-year-old girl, who presented with headaches and hypertension, underwent a comprehensive workup that revealed extensive meningeal and cerebral artery anastomoses to the left internal carotid artery—itself arising from the origin of the left pulmonary artery. This unique anatomical anomaly, caused by a disturbed pattern of aortic arch regression, resulted in a right-to-left vascular shunt into the pulmonary artery and a disturbance of intracranial artery flow patterns, complicating the management options.
Two carotid ophthalmic artery aneurysms with incorporation of the artery into the neck were refer... more Two carotid ophthalmic artery aneurysms with incorporation of the artery into the neck were referred for endovascular assessment. Temporary balloon occlusion at the aneurysm neck was performed in an attempt to assess the adequacy of collateral flow to the retina. During inflation, the patients reported visual deterioration that resolved upon deflation, which indicates that collateral blood flow was insufficient. The patients were referred for surgical clipping to ensure preservation of the ophthalmic artery.
General Aspects The management of arteriovenous malformations (AVMs) has evolved significantly in... more General Aspects The management of arteriovenous malformations (AVMs) has evolved significantly in the past two decades. The main goal of AVM treatment is to achieve a permanent cure with minimal morbidity or mortality to the patient, eliminating the risk of bleeding and all related symptoms such as seizures and neurologic deficits. The available methods of treatment include surgical resection with microsurgical techniques, radiosurgery, endovascular treatment with embolization, or a combination of these techniques. Understanding the natural history of this disease has improved and helped to guide decisions regarding treatment strategies. Combined with the increased number of therapeutic options, this has resulted in improved clinical outcomes. Despite advances in radiosurgery and endovascular techniques, surgical resection continues to play an important role in the management of brain AVMs. The most obvious advantage is that it affords immediate cure, but its more invasive nature compared with other options does entail certain risks. Radiosurgery, performed either alone or with endovascular embolization, has made possible the safe and effective treatment of some brain AVMs without the need for craniotomy, but it does carry the risk of radiation injury to adjacent normal tissue and delayed onset of cure. Although a detailed discussion regarding microsurgical resection and radiosurgery for treatment of brain AVMs is beyond the scope of this article, the reader should be aware that all treatment modalities have important roles in the management of this disease. Endovascular embolization techniques have evolved significantly in recent years. Luessenhop, who was the first to report endovascular embolization of a brain AVM, in 1960, injected pellets measuring a few millimeters in diameter and saline through a large catheter positioned in the cervical internal carotid artery that gave rise to the branches supplying the brain AVM, thus reducing its flow. Angiographic equipment has improved since that time so that images of better quality can be obtained, with flow-guided and guidewire-directed microcatheters and microwires enabling Brain Arteriovenous Malformations: Current Endovascular Strategies
In patients with subarachnoid hemorrhage (SAH), higher hemoglobin (HGB) has been associated with ... more In patients with subarachnoid hemorrhage (SAH), higher hemoglobin (HGB) has been associated with better outcomes, but packed red blood cell (PRBC) transfusions with worse outcomes. We performed a prospective pilot trial of goal HGB after SAH. Forty-four patients with SAH and high risk for vasospasm were randomized to goal HGB concentration of at least 10 or 11.5 g/dl. We obtained blinded clinical outcomes at 14 days (NIH Stroke Scale and modified Rankin Scale, mRS), 28 days (mRS), and 3 months (mRS), and blinded interpretation of brain MRI for cerebral infarction at 14 days. This trial is registered at www.stroketrials.org. Forty-four patients were randomized. Patients with goal HGB 11.5 g/dl received more PRBC units per transfusion [1 (1-2) vs. 1 (1-1), P < 0.001] and more total PRBC units [3 (2-4) vs. 2 (1-3), P = 0.045]. Prospectively defined safety endpoints were not different between groups. HGB concentration was different between study groups from day 4 onwards. The number of cerebral infarctions on MRI (6 of 20 vs. 9 of 22), NIH Stroke Scale scores at 14 days [1 (0-9.75) vs. 2 (0-16)], and rates of independence on the mRS at 14 days (65% vs. 44%) and 28 days (80% vs. 67%) were similar, but favored higher goal HGB (P > 0.1 for all). Higher goal hemoglobin in patients with SAH seems to be safe and feasible. A phase III trial of goal HGB after SAH is warranted.
✓ Intramedullary spinal cord surgery can disrupt the blood—spinal cord barrier and cause intravas... more ✓ Intramedullary spinal cord surgery can disrupt the blood—spinal cord barrier and cause intravascular contents to leak into the surgical cavity. Immediate postoperative Gd-enhanced magnetic resonance (MR) imaging can demonstrate leakage of contrast into the surgical bed and complicate the assessment of whether a residual enhancing tumor is present. The authors report a case in which the preoperative lesion was nonenhancing and not expected to enhance on postoperative imaging. A Gd-enhanced MR imaging study obtained less than 24 hours after surgery revealed that the intramedullary surgical cavity was filled with contrast material. Because of the time course and the lesion's preoperative appearance, this “enhancement” was known to be caused by the leakage of medium into the resection cavity rather than of pathological soft-tissue enhancement
✓The authors report a unique case of subarachnoid hemorrhage caused by a traumatic pseudoaneurysm... more ✓The authors report a unique case of subarachnoid hemorrhage caused by a traumatic pseudoaneurysm of the ophthalmic artery, which was successfully treated with coil embolization. Clinical and imaging features, as well as the relevant literature, are described.
ABSTRACT PURPOSE To study the effect of transfer status on endovascularly treated AIS patients&am... more ABSTRACT PURPOSE To study the effect of transfer status on endovascularly treated AIS patients' outcomes. METHOD AND MATERIALS We retrospectively analyzed consecutive anterior circulation AIS patients that underwent IAT at 4 institutions from 2006-2011. We excluded patients selected using perfusion imaging. Patient demographics, medical risk factors, presentations, technical, and clinical (NIHSS and mRS scores) outcomes, complications, and mortality were studied. Symptom-onset, groin puncture, and end-of-procedure times were recorded. THRIVE scores were calculated. Successful recanalization was defined as TIC I≥2b. Good functional outcome was defined as mRS 0-2 at 90 days. Patients were categorized into those who were transferred from outside institutions and those who presented directly to the CSCs. RESULTS 116 patients were studied. 68 (58.6%) were transferred from outside institutions. Transfers and nontransfers were similar in THRIVE scores (p=0.300), median symptom-onset to groin puncture times (306 vs. 315 minutes; p=0.572), successful recanalization (p=0.574), and symptomatic IC H (13.2 vs. 10.4, p=0.776), but differed by age (59 vs. 69 years;p=0.002), prior stroke (3% vs. 22%,p=0.002), cardiac history (17.9 vs. 36.6%,p=0.040), baseline NIHSS (20 vs. 17, p=0.005), and location of occlusion (45.6% vs. 22.9% IC A, p=0.012). Transfer patients had significantly worse outcomes at 90 days (mRS 0-2: 16.2% vs. 60.4%,p<0.001). In multivariate analysis, transfer status was an independent predictor of poor functional outcome (adj. OR 0.05, 0.011-0.222), adjusting for relevant covariates. CONCLUSION Transferred AIS patients have worse functional outcomes at 90 days than non-transfers, independent of baseline risk factors, stroke severity, time to IAT, and procedural success/complications. Further investigation should focus on residual factors that may contribute to our findings such as baseline/final infarct volumes, pre-morbid functional status, and post-stroke care. CLINICAL RELEVANCE/APPLICATION Access to intra-arterial therapy (IAT) for acute ischemic stroke (AIS) is limited to comprehensive stroke centers (CSCs) with timely access deemed critical for success. Inter-hospital transfers rep
PURPOSE Intracranial atherosclerotic disease (ICAD) is associated with significant morbidity. Sur... more PURPOSE Intracranial atherosclerotic disease (ICAD) is associated with significant morbidity. Surgical or endovascular intervention has been relegated to patients who fail medical management; but even with optimum management, the risk of recurrent strokes exists. There is no risk stratification scheme to identify this susceptible population prior to presenting with refractory strokes. We studied the differences in quantitative cerebral blood flow (qCBF) and volume (qCBV) measurements between vascular territories with and without acute infarcts in patients with advanced ICAD. METHOD AND MATERIALS We retrospectively identified 8 patients (4 Male, 4 Female; 66 +/- 14 years old) with moderate to severe intracranial stenoses (>50%) as identified with MRA within the supraclinoid ICA, ACA, MCA or PCA that had a correlative DSC-MR PWI scan at time of presentation. Vascular territories were divided into subgroups containing acute infarcts on MR DWI versus no infarcts. After the imaging se...
PURPOSE To report on a case of cranial venous outflow obstruction and intracranial venous hyperte... more PURPOSE To report on a case of cranial venous outflow obstruction and intracranial venous hypertension treated with right sigmoid sinus stent placement and angioplasty. CASE REPORT The patient was a 6-year-old male who presented with macrocephaly, prominent facial and scalp veins, limitation of strenuous activity and speech delay. On physical examination, he had a head circumference greater than 95th percentile, slight left eye extropia, bilateral optic disk pallor and decreased visual acuity. Neurologic examination was otherwise normal. One month prior to presentation, he underwent a left parietal and frontal burhole craniostomy to drain chronic bilateral subdural hematoma which was detected on his brain CT scan. The fluid collection was stable in size, with no midline shift or clinical symptoms. In our institution, a brain CT/CT angiogram was performed. Imaging findings included mild to moderate diffuse cerebral atrophy, bilateral subdural fluid collections (larger on the left) wi...
Objective: The objective was to evaluate the efficacy of percutaneous sacroplasty using both comp... more Objective: The objective was to evaluate the efficacy of percutaneous sacroplasty using both computed tomographic (CT) and fluoroscopic guidance in treatment of sacral insufficiency fractures (SIFs) with respect to pain relief and overall functional capacity. Materials and Methods: After obtaining approval from the institution’s review board, we retrospectively studied eleven consecutive patients treated by percutaneous sacroplasty in a single center from 2003 to 2008. All included patients had back pain causing restriction of activities of daily living. Using a numerical rating scale (zero (“no pain”) to ten (“worst pain imaginable”), pain assessment was performed before and after the procedure to score their pain. Results: Eleven patients underwent sacroplasty for SIFs, with a female to male ratio of 10:1. All patients presented with back pain and limited activities of daily living (ADLs). Imaging studies included CT spine (n=7), MRI spine (n=5) and whole body bone scan (n=5), wit...
Postpartum cervicocephalic artery dissection (pp-CAD) is a rare and poorly understood condition. ... more Postpartum cervicocephalic artery dissection (pp-CAD) is a rare and poorly understood condition. To our knowledge, only 21 cases have been reported. Reversible cerebral segmental vasoconstriction was first described by Call and Fleming in 1988, and its association with pp-CAD has only been reported in three cases. However, in those cases it is unclear whether the pp-CAD may have been caused by straining during labor and therefore merely coincidental to the intracranial arteriopathy. We report a 42-year-old right handed African-American woman who developed the syndrome of pp-CAD (headaches, trace sub-arachnoid hemorrhage and diffuse cerebral arteriopathy on angiogram) 2 weeks after delivery. In this unique case, the patient had fortuitously undergone an MR study twice over a 4-day period which included the carotid bifurcations. During that time the patient was an inpatient, on bed rest and subject to continuous cardiac monitoring. The interval studies documented a true spontaneous right internal carotid artery dissection occurring without obvious cause. The patient had noted moderate right neck pain developing between the two MR studies but experienced no neurological deficits. Subsequent conventional angiography confirmed the presence of postpartum cerebral arteriopathy and the cervical dissection. The patient was managed conservatively with antiplatelet medication and had an otherwise uneventful course. We hypothesize whether transient arterial wall abnormalities, postpartum hormonal changes or subtle connective tissue aberrations play a similar role in the pathogenesis of these two associated conditions.Image A: Angiogram of the right carotid bifurcation demonstrates a focal stenosis (arrow) of the right ICA distal to the bulb due to an incompletely thrombosed dissection with partial opacification of the pseudo-lumen origin (arrowhead). Image B: Cerebral angiogram shows multifocal arteriopathic beading in all territories (arrows).
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, Jan 8, 2015
We describe the novel use of a double lumen balloon catheter for venous sinus thrombolysis and ve... more We describe the novel use of a double lumen balloon catheter for venous sinus thrombolysis and venoplasty. Cerebral venous sinus thrombosis is a rare disease that is usually treated with medical anticoagulation. In certain refractory cases, surgical or endovascular thrombolysis and thrombectomy may be required. A 48year-old man on anticoagulation for cerebral venous sinus thrombosis presented with nausea, vomiting and worsening hemiparesis. The patient underwent endovascular venous sinus thrombolysis and venoplasty with continuous in situ tissue plasminogen activator (tPA) infusion over 48hours. This novel approach to the endovascular treatment of venous sinus thrombosis, including the use of a double lumen balloon was advantageous, as it allowed direct infusion of tPA through the balloon catheter without having to exchange the balloon for a microcatheter.
We describe the case of a 28-year-old obtunded woman who presented with bilateral anterior pariet... more We describe the case of a 28-year-old obtunded woman who presented with bilateral anterior parietal lobe cortical hemorrhages associated with thrombosis of the superior sagittal sinus, both transverse and sigmoid sinuses, and multiple cortical veins draining into the sagittal sinus. Initial heparin therapy was not effective. A combination of AngioJet rheolytic catheter thrombectomy, balloon angioplasty, and continuous direct superior sagittal sinus recombinant tissue plasminogen activator infusion led to venous recanalization with a successful clinical outcome, without worsening of the preexisting intracranial hemorrhages.
The authors describe what is, to their knowledge, the first reported case of the anomalous origin... more The authors describe what is, to their knowledge, the first reported case of the anomalous origin of an internal carotid artery from the pulmonary artery. An otherwise asymptomatic 6-year-old girl, who presented with headaches and hypertension, underwent a comprehensive workup that revealed extensive meningeal and cerebral artery anastomoses to the left internal carotid artery—itself arising from the origin of the left pulmonary artery. This unique anatomical anomaly, caused by a disturbed pattern of aortic arch regression, resulted in a right-to-left vascular shunt into the pulmonary artery and a disturbance of intracranial artery flow patterns, complicating the management options.
Two carotid ophthalmic artery aneurysms with incorporation of the artery into the neck were refer... more Two carotid ophthalmic artery aneurysms with incorporation of the artery into the neck were referred for endovascular assessment. Temporary balloon occlusion at the aneurysm neck was performed in an attempt to assess the adequacy of collateral flow to the retina. During inflation, the patients reported visual deterioration that resolved upon deflation, which indicates that collateral blood flow was insufficient. The patients were referred for surgical clipping to ensure preservation of the ophthalmic artery.
General Aspects The management of arteriovenous malformations (AVMs) has evolved significantly in... more General Aspects The management of arteriovenous malformations (AVMs) has evolved significantly in the past two decades. The main goal of AVM treatment is to achieve a permanent cure with minimal morbidity or mortality to the patient, eliminating the risk of bleeding and all related symptoms such as seizures and neurologic deficits. The available methods of treatment include surgical resection with microsurgical techniques, radiosurgery, endovascular treatment with embolization, or a combination of these techniques. Understanding the natural history of this disease has improved and helped to guide decisions regarding treatment strategies. Combined with the increased number of therapeutic options, this has resulted in improved clinical outcomes. Despite advances in radiosurgery and endovascular techniques, surgical resection continues to play an important role in the management of brain AVMs. The most obvious advantage is that it affords immediate cure, but its more invasive nature compared with other options does entail certain risks. Radiosurgery, performed either alone or with endovascular embolization, has made possible the safe and effective treatment of some brain AVMs without the need for craniotomy, but it does carry the risk of radiation injury to adjacent normal tissue and delayed onset of cure. Although a detailed discussion regarding microsurgical resection and radiosurgery for treatment of brain AVMs is beyond the scope of this article, the reader should be aware that all treatment modalities have important roles in the management of this disease. Endovascular embolization techniques have evolved significantly in recent years. Luessenhop, who was the first to report endovascular embolization of a brain AVM, in 1960, injected pellets measuring a few millimeters in diameter and saline through a large catheter positioned in the cervical internal carotid artery that gave rise to the branches supplying the brain AVM, thus reducing its flow. Angiographic equipment has improved since that time so that images of better quality can be obtained, with flow-guided and guidewire-directed microcatheters and microwires enabling Brain Arteriovenous Malformations: Current Endovascular Strategies
In patients with subarachnoid hemorrhage (SAH), higher hemoglobin (HGB) has been associated with ... more In patients with subarachnoid hemorrhage (SAH), higher hemoglobin (HGB) has been associated with better outcomes, but packed red blood cell (PRBC) transfusions with worse outcomes. We performed a prospective pilot trial of goal HGB after SAH. Forty-four patients with SAH and high risk for vasospasm were randomized to goal HGB concentration of at least 10 or 11.5 g/dl. We obtained blinded clinical outcomes at 14 days (NIH Stroke Scale and modified Rankin Scale, mRS), 28 days (mRS), and 3 months (mRS), and blinded interpretation of brain MRI for cerebral infarction at 14 days. This trial is registered at www.stroketrials.org. Forty-four patients were randomized. Patients with goal HGB 11.5 g/dl received more PRBC units per transfusion [1 (1-2) vs. 1 (1-1), P < 0.001] and more total PRBC units [3 (2-4) vs. 2 (1-3), P = 0.045]. Prospectively defined safety endpoints were not different between groups. HGB concentration was different between study groups from day 4 onwards. The number of cerebral infarctions on MRI (6 of 20 vs. 9 of 22), NIH Stroke Scale scores at 14 days [1 (0-9.75) vs. 2 (0-16)], and rates of independence on the mRS at 14 days (65% vs. 44%) and 28 days (80% vs. 67%) were similar, but favored higher goal HGB (P > 0.1 for all). Higher goal hemoglobin in patients with SAH seems to be safe and feasible. A phase III trial of goal HGB after SAH is warranted.
✓ Intramedullary spinal cord surgery can disrupt the blood—spinal cord barrier and cause intravas... more ✓ Intramedullary spinal cord surgery can disrupt the blood—spinal cord barrier and cause intravascular contents to leak into the surgical cavity. Immediate postoperative Gd-enhanced magnetic resonance (MR) imaging can demonstrate leakage of contrast into the surgical bed and complicate the assessment of whether a residual enhancing tumor is present. The authors report a case in which the preoperative lesion was nonenhancing and not expected to enhance on postoperative imaging. A Gd-enhanced MR imaging study obtained less than 24 hours after surgery revealed that the intramedullary surgical cavity was filled with contrast material. Because of the time course and the lesion's preoperative appearance, this “enhancement” was known to be caused by the leakage of medium into the resection cavity rather than of pathological soft-tissue enhancement
✓The authors report a unique case of subarachnoid hemorrhage caused by a traumatic pseudoaneurysm... more ✓The authors report a unique case of subarachnoid hemorrhage caused by a traumatic pseudoaneurysm of the ophthalmic artery, which was successfully treated with coil embolization. Clinical and imaging features, as well as the relevant literature, are described.
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