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In patients with subdural hematoma and an indication for surgical evacuation, middle meningeal artery embolization plus surgery led to a lower risk of reoperation for recurrence or progression within 90 days than surgery alone.

Abstract BACKGROUND The Pipeline Embolization Device (PED; Medtronic) has been used off-label for the treatment of challenging posterior circulation aneurysms. Data on this modality are primarily limited to small retrospective single-center series. OBJECTIVE To assess safety and efficacy of this treatment by establishing an international, multicenter collaboration. METHODS Consecutive posterior circulation aneurysms treated with the PED from 2012 to 2019 across 11 neurovascular centers were retrospectively reviewed. Baseline demographics, aneurysm and treatment characteristics, complications, occlusion status, and functional outcome were assessed. RESULTS There were 149 posterior circulation aneurysms treated with PED in 146 patients. A total of 24 (16.4%) patients presented with subarachnoid hemorrhage. Most aneurysms were dissecting/blister (36.2%) in morphology, followed by saccular (35.6%) and fusiform (28.2%). The most common locations were the vertebral (51.7%) and basilar arteries (22.8%). Complete or near-complete occlusion (>90%) was achieved in 90.9% of aneurysms at a median follow-up of 12 mo. Dissecting/blister aneurysms were most likely to occlude (P = .06). Symptomatic neurologic complications occurred in 9.4% of aneurysms, associated with larger size, ruptured presentation, presentations with brain stem compression, cranial nerve palsy, or stroke. Favorable functional outcome (modified Rankin Score 0-2) was achieved in 86.2% of patients. There were 6 fatalities of which 4 occurred in aneurysmal subarachnoid hemorrhage patients. CONCLUSION This multicenter study shows that PED for the treatment of posterior circulation is preferentially used for the treatment of fusiform and dissecting/blister aneurysm morphologies. Despite the challenges presented by these less-common morphologies, flow diversion may be performed with a neurologic complication rate of about 10% and favorable long-term aneurysm occlusion rates. Graphical Abstract Graphical Abstract

Abstract BACKGROUND Neck remnants are not uncommon after endovascular treatment of cerebral aneurysms. Critics of endovascular treatments for cerebral aneurysms cite neck remnants as evidence in favor of microsurgical clipping. However, studies have failed to evaluate the true clinical significance of aneurysm neck remnants following endovascular therapies. OBJECTIVE To assess the clinical significance of residual aneurysm necks and to determine the rate of subsequent rupture following coiling or stent-assisted coiling of cerebral aneurysms. METHODS We retrospectively reviewed the records of 1292 aneurysm cases that underwent endovascular treatment at 4 institutions. Aneurysms treated by primary coiling or stent-assisted coiling were included in the study; those treated by flow diversion were excluded Aneurysms with residual filling (i.e., Raymond–Roy Occlusion Classification II, neck remnant; or III, residual aneurysm filling) were assessed for their risk of subsequent rupture. RESULTS A total of 626 aneurysms were identified as having residual filling immediately posttreatment. Of these, 13 aneurysms (2.1%) ruptured during the follow-up period (mean 7.3 mo; range 1-84 mo). Eleven of the 13 (84.6%) were ruptured at presentation. Rupture at presentation, the size of the aneurysm, and the increasing age of the patient were predictive of posttreatment rupture. CONCLUSION We found that unruptured aneurysms with residual necks following endovascular treatment posed a very low risk of rupture (0.6%). However, patients presenting with ruptured aneurysms had a higher risk of rerupture from a neck remnant (3.4%). These results highlight the importance of achieving complete angiographic occlusion of ruptured aneurysms.

Abstract BACKGROUND: Occlusions of the M2 segment of the middle cerebral artery may cause significant clinical effects, especially when occurring in the dominant cerebral hemisphere, yet endovascular treatment of these lesions remains controversial. OBJECTIVE: To examine the safety and efficacy of endovascular treatment of M2 occlusions at our institution. METHODS: We retrospectively examined radiographic and clinical data of 53 patients presenting with M2 occlusions to our institution. RESULTS: Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b or 3) was achieved in 40 patients (76.9%). No symptomatic intracranial hemorrhage occurred. The mean National Institutes of Health Stroke Scale score at discharge was 6.4 (median, 5.5). In the 38 patients who had follow-up after discharge, the mean follow-up duration was 11.1 months (range, 0.5-36.5 months) and mean National Institutes of Health Stroke Scale score was 3.5 (median, 1). CONCLUSION: The results of our single-institution experience suggest that endovascular therapy for M2 occlusions is safe and effective. Additional evaluation with randomized, controlled studies is warranted.

BACKGROUND:Endovascular Pipeline Embolization Device (PED) placement for intracranial aneurysms is performed under general anesthesia at most centers because of perceived improved image quality and patient safety. OBJECTIVE:To report the feasibility, safety, and outcomes associated with the use of the PED for intracranial aneurysms performed in awake patients after the administration of conscious sedation (CS) and a local anesthetic. METHODS:Between March 2012 and September 2014, 130 patients with 139 intracranial aneurysms (8 ruptured) were treated with the PED under CS at our institution. Procedure details and time (including duration, radiation exposure, and fluoroscopy) and procedure-related complications were retrospectively reviewed. RESULTS:A total of 155 PED deployment procedures were performed under CS. Treatment was successfully completed in all cases. Anesthesia was converted from CS to general anesthesia during 5 procedures. Mean interval from patient entry at the endovascular suite to procedure initiation was 18 minutes (range, 5 minutes-1 hour 10 minutes). Mean procedure length was 1 hour 25 minutes (range, 30 minutes-3 hours 51 minutes). Mean ± SD values for fluoroscopy time and radiation exposure were 36.17 ± 18.4 minutes and 1367 ± 897 mGy, respectively. The mean amount of contrast material administered was 211.37 ± 83.5 mL. Permanent neurological complications were seen in 4 patients (3%). CONCLUSION:In our experience, CS for PED placement for intracranial aneurysm treatment is feasible and safe. Procedure and fluoroscopy times and amount of radiation exposure are similar to or less than described in reports of PED placement under general anesthesia. CS allows direct neurological evaluation and earlier detection of and response to intraprocedural complications. ABBREVIATIONS:CS, conscious sedationGA, general anesthesiaICA, internal carotid arteryPED, Pipeline Embolization Device

Multiple observations suggest that certain parasitic infections can be oncogenic. Among these, neurocysticercosis is associated with increased risk for gliomas and hematologic malignancies. We report the case of a 71-year-old woman with colocalization of a metazoan parasite, possibly cysticercosis, and a WHO grade IV neuroepithelial tumor with exclusively neuronal differentiation by immunohistochemical stains (immunopositive for synaptophysin, neurofilament protein, and Neu-N and not for GFAP, vimentin, or S100). The colocalization and temporal relationship of these two entities suggest a causal relationship.

INTRODUCTION:Dose reduction during fluoroscopy is of paramount importance. Our center has developed a novel patient-dose-savings technique for image-guided neurovascular interventions, involving a combination of a material x-ray region-of-interest (ROI) attenuator and spatially different temporal filtering. Our technique gives real-time full field-of-view as against some previous techniques of restricted view (spot fluoroscopy). We present our comparative clinical experience with standard flat panel angiography (FPA) and our technique (ROI-FPA). METHODS:Patient data (under IRB approval) from 10 patients (4 middle cerebral artery, 5 anterior communicating artery, and 1 cavernous internal carotid artery aneurysms) were acquired using rotational digital subtraction angiography and computed tomographic angiography for 3-dimesional (3-D) rendering and processing. 3-D models were generated using an Eden-260V-3-D-printer (Object-Stratasys). We performed primary coiling on the models (Figure 1) using a Toshiba Infinix C-arm. The dose incident to the patient is reduced by using a 0.7-mm-thick copper attenuator with a circular ROI hole in the middle. The attenuator is mounted inside the x-ray tube mechanism and can be deployed automatically when needed. Each 3-D printed model was treated twice, using ROI-FPA and standard FPA. A total of 80 images at varied stages of intervention were acquired. Each image was shown twice to 2 neurointerventionists and the images were rated individually. A total of answers to 400 questions (Table 1) based on visibility of aneurysm, proximal and distal vasculature, microwire, coil, and guide tip were scored. The intrarater agreements are measured by Kendall-τ-β correlation coefficient and the interrater agreements are measured by κ statistics. RESULTS:For the thickness and size of the ROI attenuator used, a total integral dose reduction of 68% was achieved. The mean scores obtained in the images when ROI was applied did not differ significantly from standard FPA images, suggesting similar image quality. The intra-rater agreement varied from (Kendall τ0.14-1) and interrater (κ0.16-0.52). CONCLUSION:Our study has shown that a significant dose reduction could be achieved without compromising the image quality during neuroendovascular interventions.

BackgroundCombining non-contrast CT (NCCT), CT angiography (CTA), and CT perfusion (CTP) imaging (referred to as a CT stroke study, CTSS) provides a rapid evaluation of the cerebrovascular axis during acute ischemic stroke. Iodinated contrast-enhanced CT imaging is not without risk, which includes renal injury. If a patient's CTSS identifies vascular pathology, digital subtraction angiography (DSA) is often performed within 24–48 h. Such patients may receive multiple administrations of iodinated contrast material over a short time period.ObjectiveWe aimed to evaluate the incidence of acute kidney injury (AKI) in patients who underwent a CTSS and DSA for evaluation of acute ischemic symptoms or for stroke intervention within a 48 h period between August 2012 and December 2014.MethodsWe identified 84 patients for inclusion in the analysis. Patients fell into one of two cohorts: AKI, defined as a rise in the serum creatinine level of ≥0.5 mg/dL from baseline, or non-AKI. Clinical parameters included pre- and post-imaging serum creatinine level, time between CTSS and DSA, and type of angiographic procedure (diagnostic vs intervention) performed.ResultsFour patients (4.7%) experienced AKI, one of whom had baseline renal dysfunction (defined as baseline serum creatinine level ≥1.5 mg/dL). The mean difference between baseline and peak creatinine values was found to be significantly greater in patients with AKI than in non-AKI patients (1.65 vs −0.09, respectively; p=0.0008).ConclusionsThis study provides preliminary evidence of the safety and feasibility of obtaining CTSS with additional DSA imaging, whether for diagnosis or intervention, to identify possible acute ischemic stroke.

Placement of ventricular reservoirs is a common practice to treat various tumors of the central nervous system (CNS). Ventricular catheter-reservoir-associated edema has been noted in the literature, but a thorough review of this literature identified no articles that examine this particular complication in neurooncology patients, specifically. We report two cases of ventricular catheter-reservoir-associated edema in patients receiving treatment for CNS metastasis.