Chemical Angioplasty with Nitroglycerin for Vasospasm after Subarachnoid Hemorrhage: Case Series and Review

Introduction Vasospasm is a common and potentially devastating complication in patients with subarachnoid hemorrhage, causing high morbidity and mortality. There is no effective and consistent way to prevent or treat cerebral vasospasm capable of altering the morbidity and mortality of this complication. Animal and human studies have attempted to show improvement in aneurysmal vasospasm. Some sought their prevention; others, the treatment of already installed vasospasm. Some achieved only angiographic improvement without clinical correlation, others achieved both, but with ephemeral duration or at the expense of very harmful associated effects. Endovascular techniques allow immediate and aggressive treatment of cerebral vasospasm and include methods such as mechanical and chemical angioplasty. These methods have risks and benefits. Objectives To analyze the results of chemical angioplasty using nitroglycerin (GTN). In addition, to performa comprehensive review and analysis of aneurysmal vasospasm. Methods We describe our series of 77 patients treated for 8 years with angioplasty for vasospasm, either mechanical (with balloon), chemical (with GTN) or both. Results Eleven patients received only balloon; 37 received only GTN; 29 received both. Forty-four patients (70.1%) evolved with delayed cerebral ischemia and 19 died (mortality of 24.7%). Two deaths were causally related to the rupture of the vessel by the balloon. The only predictors of poor outcome were the need for external ventricular drainage in the first hours of admission, and isolated mechanical angioplasty. Conclusions Balloon angioplasty has excellent results, but it is restricted to proximal vessels and is not without complications. Chemical angioplasty using nitroglycerin has reasonable but short-lived results and further research is needed about it. It is restricted to vasospasm angioplasties only in hospitals, like ours, where better and more potent vasodilator agents are not available.

Origin of the Posterior Inferior Cerebellar Artery over the C1 Posterior Arch / Origem da artéria cerebelar inferoposterior sobre o arco posterior de C1

Resumo The posterior inferior cerebellar artery usually arises from the intracranial segment (V4) of the vertebral artery. Despite its mean diameter of 2 mm, it usually irrigates important areas of the brain. When occluded, whether due to trauma or surgery, it may cause infarction in the brain stem and cerebellum. The present report describes a case of incidental finding of a posterior inferior cerebellar artery arising from the cervical segment (V3) of the vertebral artery, demonstrated by angiography. The findings were recorded and compared to those of earlier publications. Brief explanations regarding anatomy, vascular anomalies and embryology were provided. A literature review showed that anomalous branches of the cervical segment of the vertebral artery are infrequent andmust be known. A better understanding of anatomy and its variations enables an accurate topographic diagnosis, as well as the planning of the optimal surgical approach and therapy. Knowledge of this anatomical variation is essential because, if it is mistaken for a muscle branch and coagulated, this can cause ischemia and disabling sequelae.

Resumo A artéria cerebelar inferoposterior geralmente nasce do segmento intracraniano (V4) da artéria vertebral. Apesar de ter diâmetro médio de 2 mm, usualmente irriga áreas eloquentes do encéfalo. Quando ocluída, seja por trauma ou cirurgia, pode causar infarto no tronco encefálico e no cerebelo. Apresentamos um caso de artéria cerebelar inferoposterior com origem anômala no segmento cervical (V3) da artéria vertebral, demonstrado por angiografia. Os resultados foram registrados e comparados com os de publicações anteriores. Foram fornecidas breves explicações sobre a anatomia, anomalias vasculares e embriologia. A revisão da literatura mostrou que os ramos anômalos do segmento cervical da artéria vertebral são infrequentes e devem ser conhecidos. Uma melhor compreensão da anatomia e suas variações permite fazer um diagnóstico topográfico preciso, bem como planejar a abordagem e a terapia cirúrgicas ideais. O conhecimento dessa variação anatômica é essencial, pois, se confundida com um ramo muscular e coagulada, pode causar isquemia com sequelas incapacitantes.

Cerebral Proliferative Angiopathy: Case Report

Proliferative angiopathy (PA) is a rare cerebral vascular disease in which anomalous vessels continually recruit additional feeder arteries, amid a functional brain parenchyma. We report the case of a young woman with progressive history of headache, motor deficit, seizures and drowsiness. She received a misdiagnosis of brain arteriovenous malformation (AVM) and evolved with dysarthria and cognitive decline after an unsuccessful embolization performed at another institution. We opted for conservative treatment with periodic control by imaging tests. Proliferative angiopathy differs in natural history, prognosis, histopathology and treatment of the usual AVMs. Endovascular procedures aggravate the neurological deficits, which are usually progressive and tend to worsen over time.

A angiopatia proliferativa (AP) é uma doença vascular cerebral rara em que vasos anômalos recrutam continuamente artérias nutridoras adicionais em um parênquima cerebral normal. Relatamos um caso de uma mulher jovem com história progressiva de cefaleia, déficit motor, convulsões e sonolência. Ela recebeu um diagnóstico incorreto da malformação arteriovenosa (MAV) cerebral e evoluiu com disartria e declínio cognitivo após uma embolização malsucedida realizada em outra instituição. Optamos pelo tratamento conservador com controle periódico por testes de imagem. A AP difere das MAVs usuais em relação a história natural, prognóstico, histopatologia e tratamento. Os procedimentos endovasculares agravam os déficits neurológicos, que geralmente são progressivos e tendem a piorar ao longo do tempo.

Cognitive and psychiatric changes as first clinical presentation in Sneddon Syndrome / Alterações cognitivas e psiquiátricas como primeira apresentação clínica na Síndrome de Sneddon

ABSTRACT Sneddon syndrome (SS) is a rare progressive non-inflammatory thrombotic vasculopathy affecting small/medium-sized blood vessels of unknown origin. It is strongly associated with the presence of antiphospholipid antibodies (AA). The presence of livedo reticularis and cerebrovascular disease are hallmark features. The condition is far more common in young women. We report a case of SS in a 43 year-old male with a two-year history of progressive cognitive impairment consistent with dementia syndrome, and major personality changes, besides livedo reticularis and cerebral angiographic pattern of vasculitis. AA were borderline. The recognition of skin blemishes that precede strokes should raise the hypothesis of SS. AA are elevated in more than half of cases, but their role in the pathogenesis or association of positive antibodies and SS remains unclear. Dementia syndrome in young patients should be extensively investigated to rule out reversible situations. Typical skin findings, MRI and angiography may aid diagnosis.

RESUMO A síndrome de Sneddon (SS) é uma vasculopatia trombótica não inflamatória progressiva rara que afeta os vasos sanguíneos de pequeno e médio tamanho com origem desconhecida. Está fortemente associada à presença de anticorpos antifosfolipídios (AA). A presença de livedo reticularis e doença cerebrovascular são a marca registrada. É muito mais comum em mulheres jovens. Relatamos um caso de SS em um homem de 43 anos de idade com dois anos de história de comprometimento cognitivo progressivo compatível com síndrome demencial e mudanças graves de personalidade, além de livedo reticular e padrão angiográfico cerebral de vasculite. AA eram limítrofes. O reconhecimento das manchas da pele que precedem eventos isquêmicos cerebrovasculares deve reforçar a hipótese de SS. Os AA são elevados em mais da metade dos casos, mas seu papel na patogênese ou associação de anticorpos positivos e SS permanece obscuro. A síndrome demencial em pacientes jovens deve ser amplamente investigada para se descartarem situações reversíveis. Achados típicos da pele, ressonância magnética e angiografia podem ajudar no diagnóstico.

Endovascular Treatment of a Giant Dissecting Aneurysm in an Infant

Introduction The incidence of intracranial aneurysms in the pediatric population is low, and endovascular treatment is becoming a safe and minimally invasive treatment option. In the present study, the occurrence of special features of cerebral aneurysm in children, in comparison to adults, is also described. Case Report A 3-month-old female infant presented with progressive proptosis and divergent strabismus at the right eye, in addition to inconsolable crying. Cerebral resonance, angiotomography and angiography exams demonstrated angiodysplasia in the right internal carotid artery with two large paraclinoid dissecting aneurysms with wide neck. The right internal carotid artery was occluded with coils by endovascular approach, without detriment to the perfusion of the ipsilateral hemisphere and without neurological deficits. The patient achieved good recovery, and a late control angiotomography confirmed the exclusion of the aneurysms. Conclusion Parent artery sacrifice via endovascular approach is an effective therapeutic option, but a long-termfollow-up is necessary to avoid recurrence and bleeding.

Intra-arterial Thrombectomy with Stent Retriever for Acute Ischemic Stroke ­ a Retrospective, Single-centered Study from Brazil

Objective To report our initial experience with intra-arterial thrombectomy (IAT) with stent retriever for acute ischemic stroke. Methods We conducted a retrospective review of patients with acute ischemic stroke who underwent IAT from September 2010 to August 2016. Results Forty-one patients were included; mean age was 57 years (range: 29­85), and 54% were women. There were 32 anterior circulation occlusions, and 11 posterior circulation occlusions. The mean value of the National Institutes of Health Stroke Scale (NIHSS) upon admission (available in 9/41 patients) was 14 (range: 6­20). Nineteen patients had favorable outcomes (modified Rankin Scale [mRS]: 0­2 at 6 months), and 22 had unfavorable outcomes (mRS: 3­6 at 6 months). The mortality rate was 37% (15/41). Favorable outcomes were associated with revascularization within the first 360 minutes of the onset of symptoms (p » 0.000001), and satisfactory revascularization (thrombolysis in cerebral infarction [TICI] scale: 2b or 3) (p » 0.0018). Conclusion It is of paramount importance to educate stroke teams on the benefits of IAT for acute ischemic stroke and the population on identifying stroke and seeking immediate care following symptom onset.

Objetivo Relatar nossa experiência inicial com trombectomia intra-arterial (TIA) com uso de stent retriever em acidente vascular encefálico isquêmico (Avei) agudo. Métodos Análise retrospectiva de pacientes com Avei submetidos a TIA de setembro de 2010 a agosto de 2016. Resultados Foram incluídos 41 pacientes; a idade média foi 57 anos (intervalo: 29­85), e 54% dos pacientes eram mulheres. Trombos ocluindo vasos da circulação anterior foram encontrados em 32 casos, e 11 na circulação posterior. A média do valor da Escala de Acidente Vascular Encefálico do National Institutes of Health (NIH) na admissão (disponível para 9 dos 41 pacientes) foi 14 (intervalo: 6­20). Um total de 19 pacientes teve resultados favoráveis (Escala de Rankin modificada [ERm]: 0­2 em 6 meses), e 22 tiveram resultados não favoráveis (ERm: 3­6 em 6 meses). A mortalidade foi de 37% (15/41). Resultados favoráveis foram associados com revascularização dentro dos primeiros 360 minutos de instalação dos sintomas (p » 0.000001) e revascularização satisfatória (escala de trombólise em infarto cerebral [TEIC]: 2b ou 3) (p » 0.0018). Conclusão É de suma importância educar as equipes de acidente vascular encefálico sobre os benefícios da TIA para Avei agudo, e a população, na identificação do Avei, para que seja buscado atendimento imediato após o início dos sintomas.

Physicians are not well informed about the new guidelines for the treatment of acute stroke / Os médicos não estão bem informados sobre as novas diretrizes para o tratamento de AVC agudo

ABSTRACT Treatment of cerebrovascular disease has advanced rapidly in the last two decades. Recent data has added challenges to the treatment of ischemic stroke in the acute phase. Objective: To evaluate the knowledge of physicians about the treatment of ischemic stroke in the acute phase. Methods: An online questionnaire was submitted to all physicians enrolled in the Regional Council of Medicine in Brazil. Results: 456 physicians from different specialties answered the questions. Most of them did not know that mechanical endovascular thrombectomy is often considered as the gold standard treatment in cases of ischemic stroke in the acute phase; and 85% of them did not realize that thrombectomy together with intravenous thrombolysis was possible. The maximum time to act in an acute event also presented many divergences, even with regard to the infusion of rtPA. The lack of structure, medication and absence of a neurologist were considered the main barriers to treatment. Conclusion: Physicians are not well informed about the new guidelines for the treatment of acute stroke. Most physicians incorrectly answered most of the questions on the questionnaire.

RESUMO O tratamento da doença cerebrovascular tem avançado rapidamente nas últimas duas décadas. Dados recentes acrescentaram desafios ao tratamento do AVC isquêmico na fase aguda (AIFA). Objetivo: Avaliar o conhecimento médico sobre o tratamento do AIFA. Métodos: Um questionário on-line foi submetido a todos os médicos inscritos no Conselho Regional de Medicina. Resultados: 456 médicos de diferentes especialidades responderam às perguntas. A maioria deles não sabia que a trombectomia endovascular mecânica é freqüentemente considerada como tratamento padrão-ouro nos casos de AIFA. 85% não realizariam trombectomia junto com a trombólise intravenosa. O tempo máximo para atuar no evento agudo também apresentou muitas divergências, mesmo em relação à infusão de rtPA. A falta de estrutura, medicação e neurologista foram consideradas as principais barreiras ao tratamento. Conclusão: Os médicos não estão bem informados sobre as novas diretrizes para o tratamento do AIFA. A maioria dos médicos errou a maioria das perguntas desse questionário.

Anterior temporal lobectomy versus selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy / Lobectomia temporal anterior versus amigdalohipocampectomia seletiva para epilepsia de lobo temporal mesial

ABSTRACT Objective To contribute our experience with surgical treatment of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH). Method This is a retrospective observational study. The sample included patients with medically refractory mTLE due to unilateral mesial temporal sclerosis who underwent either ATL or SelAH, at Hospital de Clinicas – UFPR, from 2005 to 2012. We report seizure outcomes, using Engel classification, cognitive outcomes, using measurements of verbal and visuospatial memories, as well as operative complications. Result Sixty-seven patients (33 ATL, 34 SelAH) were studied; median follow-up was 64 months. There was no statistically significant difference in seizure or neuropsychological outcomes, although verbal memory was more negatively affected in ATL operations on patients’ dominant hemispheres. Higher number of major complications was observed in the ATL group (p = 0.004). Conclusion Seizure and neuropsychological outcomes did not differ. ATL appeared to be associated with higher risk of complications.

RESUMO Objetivo Contribuir com nossa experiência para o tratamento cirúrgico de pacientes com epilepsia do lobo temporal mesial submetidos a lobectomia temporal anterior (LTA) ou amigdalohipocampectomia seletiva (AHS). Método Estudo retrospectivo observacional. Foram incluídos pacientes com epilepsia refratária devido a esclerose mesial temporal unilateral, submetidos a LTA ou AHS no Hospital de Clínicas – UFPR, entre 2005-2012. Foram comparados os resultados cognitivos (análises de memórias verbal e visuoespacial), controle de crises (Engel) e complicações cirúrgicas. Resultados Sessenta e sete pacientes (33 LTA, 34 AHS) foram estudados; o período de acompanhamento médio foi de 64 meses. Não houve diferença no controle das crises ou resultado neuropsicológico, mas a memória verbal foi mais negativamente afetada nos pacientes submetidos à LTA no hemisfério dominante. Maior número de complicações graves ocorreu no grupo de LTA (p = 0.004). Conclusão Controle de crises e resultados neuropsicológicos não diferiram. LTA pareceu estar associada a um maior risco cirúrgico.

Intraventricular hemorrhage secondary to AVM of the septum pellucidum / Hemorragia intraventricular secundária a MAV de septum pellucidum

Arteriovenous malformations (AVMs) of the brain include congenital vascular lesions that represent about 2% of all hemorrhagic strokes. Despite the relative rarity of the disease (with a detection rate estimated at approximately 1/100.000 person-years), AVMs represent a significant neurological problem. Affected patients are mostly young and healthy. AVMs located in the medial region of the cerebral hemisphere and the limbic system comprise a special group with difficult access and consequent difficulties of resection. Furthermore, there is a high incidence of intracranial hemorrhage resulting from a complex venous drainage, sometimes directed to the superficial veins, but mostly to the deep venous system. The present case report illustrates a patient with an AVM centered on the septum pellucidum, whose initial clinical resulted from an intra-ventricular hemorrhage.

Malformações arteriovenosas (MAVs) encefálicas são lesões vasculares congênitas que representam cerca de 2% de todos os acidentes vasculares hemorrágicos. Embora se tratando de uma doença relativamente rara (com prevalência estimada em aproximadamente 1/100.000 pessoas-ano), MAVs representam um problema neurológico significativo. Os pacientes afetados são na maioria jovens e hígidos. MAVs localizadas na região medial do hemisfério cerebral e no sistema límbico correspondem a um grupo especial pela dificuldade de acesso e consequente dificuldade de ressecção. Além disso, possuem alta incidência de hemorragia intracraniana resultante de uma drenagem venosa complexa, por vezes direta às veias superficiais, mas na maioria para os sistemas venosos profundos. O caso relatado a seguir ilustra um paciente com uma MAV centrada no septum pellucidum, cuja apresentação clínica inicial resultou de uma hemorragia intraventricular.

Tratamiento endovascular plurimodal de aneurismas múltiples de la circulación anterior. Reporte de un caso / Multimodalities endovascular treatment of multiple aneurysms of the anterior circulation. Case report

Aneurismas cerebrales son una enfermedad grave, a pesar del alto grado de conocimiento respecto su fisiopatología y patogenia. La letalidad de ruptura de un aneurisma cerebral es todavía alrededor de 50%, allá de altas tasas de morbilidad. El tratamiento endovascular ha evolucionado en las últimas décadas para mejorar los resultados. Se presenta el caso de un paciente con síntomas neurológicos graves secundarios a la hemorragia subaracnoidea, cuya investigación mostró múltiples aneurismas. Varios dispositivos fueron utilizados en modalidades terapéuticas endovasculares consecutivas, incluyendo la embolización con remodelación, colocación de stents y desviador de flujo, con buen resultado clínico y angiográfico.

Cerebral aneurysms are a serious illness, despite the high degree of knowledge about its pathophysiology and pathogenesis. The lethality of cerebral aneurysm´s rupture is still about 50% beyond high morbidity. Endovascular treatment has evolved in recent decades to improve outcomes. It is reported the case of a patient with severe neurological symptoms secondary to subarachnoid hemorrhage, whose examination showed multiple aneurysms. Several devices were used on consecutive endovascular therapeutic modalities, including remodeling embolization, stenting and flow diverter, with good clinical and angiographic outcome.