A new subtype of intracranial dural AVF according to the patterns of venous drainage.

BACKGROUND AND PURPOSE: A well-known classification of dural arteriovenous fistulas (DAVFs) according to the patterns of venous drainage was described in 1977 by Djindjian, Merland et al. and later revised by Cognard, Merland et al. in 1995. They described 5 types of DAVFs assuming that the type of venous drainage is directly correlated with neurologic symptoms and in particular with hemorrhagic risk. We present a series of cases that combines type IV (DAVF with cortical venous drainage associated with venous ectasia) and type V (DAVF with spinal venous drainage), which we named type IV + V. MATERIALS AND METHODS: A retrospective study between 2012 and 2020 in 2 Hospitals was performed on patients that met inclusion criteria for a diagnosis of this type of DAVF. Demographics, location, clinical presentation and outcomes of endovascular embolization were studied. RESULTS: Five (2,3%) patients out of 220 had a type IV + V DAVF. All cases had an aggressive presentation, either subarachnoid hemorrhage, myelopathy or both. All patients were treated with endovascular transarterial embolization achieving complete angiographic occlusion in one session and total remission of symptoms at 3 months. CONCLUSIONS: This rare type of DAVF, combines two aggressive venous drainage patterns. For that reason, patients with type IV+V DAVF probably have a more aggressive natural history and worst outcome due to risk of intracranial and/or spinal hemorrhage and myelopathy, thus requiring urgent diagnostic and treatment. Larger studies are needed to better understand this type of DAVF.

Arteriovenous fistulas of the Vein of Galen region in adults: Endovascular treatment.

PURPOSE: Arteriovenous fistulas of the Vein of Galen region in adults (Ad-VGAVF) are an uncommon entity with specific anatomic features. The aim of this article is to present our experience in the endovascular treatment of this pathology and to propose a therapeutic strategy based precisely on the angioarchitecture of these lesions. MATERIALS AND METHODS: During a 20-year period, 10 patients underwent endovascular treatment of Ad-VGAVF. They were nine men and one woman with a mean age of 50 years (23-66 years) treated with the same embolization strategy. Clinical presentation, angiographic characteristics, therapeutic strategy, and clinical outcomes were recorded. RESULTS: All patients were treated exclusively by endovascular approach. Transarterial access was performed in eight patients and combined transvenous and transarterial access in two. Complete obliteration of the fistula was obtained in all patients. There were no intraprocedural complications. Post-embolization neurological symptoms occurred in 5 of 10 with complete resolution at six months in all of them. CONCLUSION: Arteriovenous fistulas of the Vein of Galen region in adults present uniform angioarchitecture despite their low prevalence. Based on this constant angioarchitecture and especially on the features of its venous drainage, judicious embolization strategy is feasible and effective. Ten cases treated entirely by endovascular approach with excellent clinical and angiographic outcomes show this treatment like a curative alternative for this entity of deep topography and severe prognosis.

Endovascular treatment for acute ischemic stroke patients: implications and interpretation of IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials: A report from the Working Group of International Congress of Interventional Neurology.

OBJECTIVE: The results of Interventional Management of Stroke (IMS) III, Magnetic Resonance and REcanalization of Stroke Clots Using Embolectomy (MR RESCUE), and SYNTHESIS EXPANSION trials are expected to affect the practice of endovascular treatment for acute ischemic stroke. The purpose of this report is to review the components of the designs and methods of these trials and to describe the influence of those components on the interpretation of trial results. METHODS: A critical review of trial design and conduct of IMS III, MR RESCUE, and SYNTHESIS EXPANSION is performed with emphasis on patient selection, shortcomings in procedural aspects, and methodology of data ascertainment and analysis. The influence of each component is estimated based on published literature including multicenter clinical trials reporting on endovascular treatment for acute ischemic stroke and myocardial infarction. RESULTS: We critically examined the time interval between symptom onset and treatment and rates of angiographic recanalization to differentiate between "endovascular treatment" and "parameter optimized endovascular treatment" as it relates to the IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials. All the three trials failed to effectively test "parameter optimized endovascular treatment" due to the delay between symptom onset and treatment and less than optimal rates of recanalization. In all the three trials, the magnitude of benefit with endovascular treatment required to reject the null hypothesis was larger than could be expected based on previous studies. The IMS III and SYNTHESIS EXPANSION trials demonstrated that rates of symptomatic intracerebral hemorrhages subsequent to treatment are similar between IV thrombolytics and endovascular treatment in matched acute ischemic stroke patients. The trials also indirectly validated the superiority/equivalence of IV thrombolytics (compared with endovascular treatment) in patients with minor neurological deficits and those without large vessel occlusion on computed tomographic/magnetic resonance angiography. CONCLUSIONS: The results do not support a large magnitude benefit of endovascular treatment in subjects randomized in all the three trials. The possibility that benefits of a smaller magnitude exist in certain patient populations cannot be excluded. Large magnitude benefits can be expected with implementation of "parameter optimized endovascular treatment" in patients with ischemic stroke who are candidates for IV thrombolytics.

Natural history of acute stroke due to occlusion of the middle cerebral artery and intracranial internal carotid artery.

BACKGROUND AND PURPOSE: The natural history of acute ischemic stroke (AIS) due to anterior circulation large artery occlusion is not well established. This information is essential for assessment of clinical benefit derived from recanalization therapies. METHODS: Patients with AIS due to anterior circulation large artery occlusion not treated with reperfusion therapies admitted from January 2005 to September 2010 were consecutively selected. Site of occlusion was assessed with transcranial duplex according to Thrombolysis in Brain Infarction (TIBI) grades. Poor outcome was considered as a modified Rankin Scale>2 at 90 days. RESULTS: A total of 120 patients were studied. Site of occlusion was terminal internal carotid artery (TICA) in 13 (10.8%), proximal middle cerebral artery (MCA) in 69 (57.5%), and distal MCA in 38 (31.7%) patients. Overall, 74.2% of patients had poor outcome. There were significant differences in poor outcome between patients with TICA, proximal MCA, and distal MCA occlusion (92%, 87%, 47%, P < .001) and mortality at 90 days (23%, 12%, 3%, P = .001). CONCLUSIONS: Outcome of AIS patients with anterior circulation large artery occlusion not treated with reperfusion therapies is extremely poor in TICA and proximal MCA occlusions with better outcomes noted in distal MCA occlusions. These findings are relevant for estimation of treatment effect of reperfusion therapies according to occlusion location.

Superselective intracerebral catheterization for administration of oncolytic virotherapy in a case of diffuse intrinsic pontine glioma.

New therapies are needed to improve current results in diffuse intrinsic pontine glioma. We present here the initial experience of administering Celyvir, autologous mesenchymal stem cells infected with ICOVIR-5, an oncolytic adenovirus that selectively replicates in cancer cells, by means of superselective intra-arterial delivery, in a patient diagnosed of diffuse intrinsic pontine glioma. Feasibility, safety, and morbidity rates of the superselective catheterization technique are comparable with those of diagnostic angiography. The intra-arterial approach warrants a greater contact of the mesenchymal stem cells with the tumor mass, and minimizes hemorrhages or vascular disruption. The tolerance to the 2 administrations was excellent, with no acute or delayed adverse effect, underscoring the feasibility of this technique for the delivery of virotherapies and/or cellular therapies in this location.

Hemorrhagic risk of emergent endovascular treatment plus stenting in patients with acute ischemic stroke.

BACKGROUND: Several endovascular revascularization strategies have been described for the treatment of acute ischemic stroke (AIS). One of them is stenting when a very narrow stenosis with high reocclusion risk remains after recanalization. This study describes the risk of symptomatic intracerebral hemorrhage (SICH) after emergent stenting in patients with AIS treated with endovascular therapies. METHODS: Consecutive patients who underwent endovascular treatment over a 37-month period were retrospectively analyzed. Patients were classified in 2 groups: (1) patients in whom a stent was deployed; and (2) patients without stenting. Double antiplatelet treatment with aspirin and clopidogrel was administered at the time of stenting. SICH was defined as any hemorrhagic transformation with National Institutes of Health Stroke Scale (NIHSS) score worsening 4 points or more (European-Australasian Acute Stroke Study II criteria). RESULTS: A total of 143 patients were included (mean age: 66.1±11.7 years, median NIHSS score: 18). Acute phase stenting was performed in 24 subjects (16.8%): 4 intracranial (3 in basilar artery, 1 in middle cerebral artery) and 20 extracranial (internal carotid artery). SICH occurred in 11 patients, 5 of 24 (20.8%) in patients with stenting and in 3 of 119 (2.5%) without (P=.008). No differences were found with respect to baseline NIHSS score or intravenous tissue plasminogen activator administration. Acute phase stenting emerged as an independent predictor of SICH after adjustment for potential confounders and procedure duration: odds ratio 7.3 (confidence interval 1.4-36.8, P=.016). CONCLUSIONS: Our findings suggest that emergent stenting in endovascular treatment of AIS is associated with SICH.

Endovascular revascularization of chronic symptomatic vertebrobasilar occlusion.

BACKGROUND AND PURPOSE: Acute basilar artery occlusion is associated with a high risk of stroke, mortality, and poor outcome in survivors. Timely vessel revascularization is critical to improve the clinical outcome in this condition. A subset of patients survives acute occlusion with mild or no disability and some of these individuals develop recurrent ischemic events despite optimal medical therapy. The strategy for management of these patients is unknown. CASE SUMMARY: We described 3 patients with chronic intracranial vertebrobasilar occlusions who presented with recurrent ischemic symptoms and progressive disability. All 3 patients were treated successfully with angioplasty and stenting. One patient experienced headache postprocedure and was found to have subarachnoid hemorrhage, which was self-limiting without need for intervention or result in permanent neurological sequela. All 3 patients have been free of recurrent symptoms for up to 30 months. CONCLUSIONS: Revascularization of chronic vertebrobasilar occlusions is technically feasible. Due to the high-risk nature, it should be reserved as an option only for selected group of patients with recurrent ischemic symptoms and progressive disability despite maximal medical therapy. Further prospective study is helpful to clarify the role of this intervention.

Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience.

BACKGROUND AND PURPOSE: Acute ischemic stroke due to tandem occlusions of the extracranial internal carotid artery and intracranial arteries has a poor natural history. We aimed to evaluate our single-center experience with endovascular treatment of this unique stroke population. METHODS: Consecutive patients with tandem occlusions of the internal carotid artery origin and an intracranial artery (ie, internal carotid artery terminus, M1 middle cerebral artery, or M2 middle cerebral artery) were studied retrospectively. Treatment consisted of proximal revascularization with angioplasty and stenting followed by intracranial intervention. Endpoints were recanalization of both extracranial and intracranial vessels (Thrombolysis In Myocardial Ischemia ≥2), parenchymal hematoma, and good clinical outcome (modified Rankin Scale ≤2) at 3 months. RESULTS: We identified 77 patients with tandem occlusions. Recanalization occurred in 58 cases (75.3%) and parenchymal hematoma occurred in 8 cases (10.4%). Distal embolization occurred in 3 cases (3.9%). In 18 of 77 patients (23.4%), distal (ie, intracranial) recanalization was observed after proximal recanalization, obviating the need for distal intervention. Good clinical outcomes were achieved in 32 patients (41.6%). In multivariate analysis, Thrombolysis In Myocardial Ischemia ≥2 recanalization, baseline National Institutes of Health Stroke Scale score, baseline Alberta Stroke Programme Early CT score, and age were significantly associated with good outcome. CONCLUSIONS: Endovascular therapy of tandem occlusions using extracranial internal carotid artery revascularization as the first step is technically feasible, has a high recanalization rate, and results in an acceptable rate of good clinical outcome. Future randomized, prospective studies should clarify the role of this approach.

Endovascular therapy for cardiac catheterization associated strokes.

BACKGROUND: Stroke is one of the most feared complications after cardiac catheterization. Endovascular treatment combining mechanical and pharmacological therapy has been reported as an effective treatment option in selected patients with acute stroke due to large-vessel occlusion. Little is known about safety and clinical outcome when this approach is utilized in cardiac catheterization associated strokes. METHODS AND RESULTS: We analyzed clinical and radiological characteristics and outcomes in the endovascular acute stroke treatment databases from two University Hospitals from July 2006 to December 2008 (Cleveland Clinic Foundation) and September 1999 and December 2008 (UPMC Presbyterian hospital), respectively. Of a total of 419 acute stroke interventions, 14 (3.34%) were identified as strokes during or immediately after cardiac catheterization. The mean age was 71 ± 7 years; eight were women (57.1%). Mean National Institute of Health Stroke Scale was 17 (±7.6). Four patients underwent intravenous thrombolysis followed by intraarterial intervention. Median time to treatment was 240 minutes from last time seen normal (range 66-1,365 minutes). Seven patients (50%) had a favorable outcome (modified Rankin Scale [mRS]≤ 2). In-patient mortality was 42%. CONCLUSION: In acute strokes following cardiac catheterization, multimodal endovascular therapy is safe and feasible and despite a high mortality is associated with a higher than expected rate of favorable outcomes compared to the natural history of the disease. Despite a significant proportion of patients developing symptoms in hospitals where neurointerventions are available, the median time to treatment was longer than expected. Future efforts should focus on faster implementation of recanalization therapies for this form of acute stroke.

Endovascular treatment of atypical posterior circulation aneurysms: technical results and review of the literature.

BACKGROUND: we report our technical success and complication rates in treating posterior circulation aneurysms at sites other than the basilar apex, superior cerebellar artery origin, or the posterior inferior cerebellar artery origin via endovascular embolization or sacrifice. MATERIALS AND METHODS: we retrospectively reviewed case records for patients undergoing coil embolization of atypical posterior circulation aneurysms from January 2003 to December 2007. RESULTS: thirty-two aneurysms in 32 patients were treated. Twenty-one patients (65%) presented with a subarachnoid hemorrhage. Twenty-two aneurysms were treated with coiling alone, 9 with stent-assisted coiling, and 1 with a combination of Onyx plus stent-assisted coiling. Twelve aneurysms were treated with vessel sacrifice. Immediately post procedure, 27/32 aneurysms (84%) were considered successfully treated, resulting in either vessel sacrifice, complete obliteration, or minimal neck remnant. Sixteen of 19 patients (84%) were considered successfully treated at a mean angiographic follow up of 8 months. The procedural morbidity and mortality was 15% and 6% respectively. CONCLUSION: endovascular embolization remains a viable and durable method of treatment for atypical posterior circulation aneurysms.

In-stent thrombosis and stenosis after neck-remodeling device-assisted coil embolization of intracranial aneurysms.

BACKGROUND: Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling devices in the treatment of intracranial aneurysms. OBJECTIVE: To examine the technical and anatomic factors that predict short- and long-term stent patency. METHODS: We undertook a retrospective review of 161 patients who underwent coil embolization of 168 ruptured and unruptured aneurysms assisted by the use of a neck-remodeling device. One hundred twenty-seven patients had catheter-based angiographic follow-up to evaluate 133 stent-coil constructs (mean, 15.4 months; median, 12.7 months). The technique of microcatheter jailing was used in a majority of patients; nonstandard stent configurations were also used. RESULTS: Clinical follow-up for all patients who had catheter-based angiograms demonstrated that among 133 stent constructs, a total of 9 (6.8%) had an in-stent event: 6 acute or subacute thrombosis (4.5%) and 3 delayed stenosis or occlusion (2.3%). Seven of these constructs were associated with a symptomatic event (5.3%). A significantly higher rate of in-stent events was seen with the use of constructs to treat anterior communicating artery aneurysms. When all patients are considered, including those who did not receive catheter-based follow-up imaging, 2 of 168 procedures (1.2%) resulted in the death of a patient, and procedural morbidity was 14.9%. CONCLUSION: From these results and those in the published literature, in-stent complication rates are low in carefully selected patients. The use of dual antiplatelet therapy, sensitivity assays, and glycoprotein IIb/IIIa inhibitors may decrease the rate of acute and chronic in-stent complications.

Comparison of safety and clinical and radiographic outcomes in endovascular acute stroke therapy for proximal middle cerebral artery occlusion with intubation and general anesthesia versus the nonintubated state.

BACKGROUND AND PURPOSE: There is considerable heterogeneity in practice patterns between sedation in the intubated state vs nonintubated state during endovascular acute stroke therapy. We sought to compare clinical and radiographic outcomes between these 2 sedation modalities. METHODS: Consecutive patients with acute stroke due to middle cerebral artery-M1 segment occlusion treated with endovascular therapy between January 2006 and July 2009 were identified in our interventional acute stroke database. Level of sedation was determined as intubated (IS) vs nonintubated (NIS) state. Final infarct volumes on follow-up imaging and clinical outcomes at 3 to 6 months were obtained. RESULTS: A total of 126 patients were included (73 [58%] NIS vs 53 [42%] IS). In IS patients, intensive care unit length of stay was longer (6.5 vs 3.2 days, P=0.0008). Intraprocedural complications were lower in NIS patients compared with IS patients (5/73 [6%] vs 8/53 [15%], respectively), but the difference was not significant (P=0.13). In univariate and multivariate analyses, NIS was significantly associated with in-hospital mortality (odds ratio=0.32, P=0.011), good clinical outcome (odds ratio=3.06, P=0.042), and final infarct volume (odds ratio=0.25, P=0.004). CONCLUSIONS: In endovascular acute stroke therapy, treatment of patients in NIS appears to be as safe as treatment in IS and may result in more favorable clinical and radiographic outcomes. Our preliminary observations derived from this retrospective study await confirmation from prospective trials.

Endovascular treatment of basilar artery occlusion by manual aspiration thrombectomy.

BACKGROUND AND PURPOSE: Basilar artery occlusion remains one of the most devastating subtypes of stroke. Intravenous and intra-arterial therapy have altered the natural history of this disease; however, clinical results remain poor. Therefore, exploring more aggressive and innovative management is warranted. METHODS: Six consecutive patients presenting with a basilar artery occlusion were treated with the same general algorithm of intra-arterial tissue plasminogen activator and mechanical thrombectomy with the Merci retrieval system. If complete recanalization was not achieved after two passes, manual syringe aspiration through a 4.3F catheter was employed. RESULTS: All interventions utilizing aspiration thrombectomy resulted in recanalization, with five out of six cases displaying TIMI3/TICI3 flow and one patient resulting in complete recanalization of the basilar artery with persistent thrombus in one P2 segment (TIMI2/TICI2B). All patients survived, with five out of six independent in activities of daily living at 3 months (mRS 0-2). CONCLUSIONS: Our small case series indicates that aspiration thrombectomy performed manually through a 4.3F catheter can facilitate recanalization of basilar artery occlusion with acceptable clinical outcomes.

Mechanical approaches combined with intra-arterial pharmacological therapy are associated with higher recanalization rates than either intervention alone in revascularization of acute carotid terminus occlusion.

BACKGROUND AND PURPOSE: Acute stroke attributable to internal carotid artery terminus occlusion carries a poor prognosis. Vessel recanalization is crucial to improve clinical outcome. Historically, pharmacological thrombolysis alone has low recanalization rates. We sought to determine whether adjunctive mechanical approaches achieve better vessel recanalization and functional outcome. METHODS: We retrospectively reviewed 75 consecutive endovascular cases of acute internal carotid artery terminus occlusions treated at our center between 1998 and 2008. Mechanical approaches (MERCI retrieval/angioplasty/stent) with and without adjunctive intra-arterial pharmacological therapy (urokinase or tissue plasminogen activator) was compared to intra-arterial lytics alone. Univariate and multivariate analyses were performed to determine predictors of recanalization (thrombolysis in myocardial infarction grades 2 to 3) and favorable functional outcome (modified Rankin score

The promise and potential pitfalls of serum biomarkers for ischemic stroke and transient ischemic attack.

BACKGROUND: Ischemic stroke and transient ischemic attack can be difficult to diagnose clinically, and both acute and preventive therapies carry some risk. Serum biomarkers could increase diagnostic certainty by helping to distinguish cerebral ischemia from common mimics such as focal seizure, complicated migraine, and psychogenic spells. Biomarkers could also identify patients at high risk for future vascular events, which would aid in management decisions. REVIEW SUMMARY: There are many potential obstacles to finding these biomarkers, which are reviewed here, including the blood brain barrier, confounding by other conditions, and imperfect gold standards for use in validation. Diagnostic biomarkers are likely to be molecules found predominantly in brain tissue with rapid entry into the blood, whereas risk-stratification biomarkers may be related to the concept of an active atherosclerotic plaque. Many promising serum molecules have been examined in small series of patients with cerebrovascular disease. CONCLUSION: Large series examining many candidate molecules will be needed to find valid biomarkers, and this should be followed by use in future intervention trials to prove their utility.

Cervicocerebral arterial dissection.

Dissection of the cervicocerebral arteries is an infrequent occurrence but is a leading cause of stroke in young and otherwise healthy patients. A brief review of the history, pathogenesis, and management is presented. The proper management for stroke prevention in dissection is unclear as there have been no randomized, controlled trials performed; small trials are under way.

Complete T2-fogging of pontomedullary infarction in Locked-In Syndrome.

We report a patient who was treated with intravenous thrombolysis, and subsequently developed a Locked-In Syndrome (LIS). After 2 days, magnetic resonance imaging showed a large bilateral pontomedullary infarction. However, in contrast to the patient's clinical situation, the follow-up T2-weighted MR images up to day 26 did not display the infarction. This phenomenon is known as the so-called fogging effect.

Hemorrhagic complications after off-label thrombolysis for ischemic stroke.

BACKGROUND AND PURPOSE: Only 2% to 4% of patients with acute ischemic stroke receive thrombolytic therapy resulting from the current strict inclusion criteria among other issues. Safety of intravenous and intraarterial thrombolysis in off-label situations is controversially discussed. We sought to review the reports on such patients regarding intra- and extracranial hemorrhage. SUMMARY OF REVIEW: A MEDLINE search for off-label uses of thrombolysis revealed reports on 273 patients treated with intraarterial or intravenous thrombolysis for ischemic stroke. Symptomatic intracranial hemorrhage occurred in 19 of 273 patients (6.95%) and extracranial hemorrhage in 17 of 273 (6.22%). CONCLUSIONS: These data suggest that the overall bleeding risk in off-label thrombolysis may not be as high as presumed. However, the small number of patients in each group and the likely underreporting of worse outcomes preclude drawing any conclusion as to specific treatment recommendations. Selected patients might benefit, however, from thrombolysis in situations not currently considered in the inclusion criteria. To obtain a meaningful database, a registry for off-label thrombolysis should be created.

Does thrombolysis benefit patients with lacunar syndrome?

The efficacy of thrombolysis in clinical stroke subtypes is unclear. We compared the benefit of intravenous rt-PA in 11 patients with lacunar syndrome with that in 33 patients with a non-lacunar syndrome. Patients were matched by NIHSS score and time to treatment. Although no statistically significant differences were detected in outcome, the benefit was greater in the non- lacunar syndrome group.

["Seronegative" myasthenia gravis and antiMuSK positive antibodies: description of Spanish series]. / Miastenia gravis "seronegativa" y anticuerpos antiMuSK positivos: descripción de una serie española.

BACKGROUND AND OBJECTIVE: Recently, the presence of antibodies to a muscle-specific tyrosine kinase (MuSK) has been reported in some patients with seronegative generalized myasthenia gravis. Our objective was to describe a group of patients who were positive for anti-MuSK antibodies. PATIENTS AND METHOD: Detection of antibodies using a radioimmunoassay was performed in the serum of 26 patients with generalized myasthenia gravis. We identified 9 patients with anti-MuSK antibodies (MuSK+). Clinical and therapeutic data from these patients were reviewed. RESULTS: Eight of nine patients were women aged between 20 and 40 years. Clinically, all of them showed prevalent bulbar signs, initially or during the progression of the disease. 77% of patients showed ocular involvement and 44% had symptoms of fatigability involving limbs. None of them improved upon thymectomy. Response to acetylcholinesterase inhibitors was variable. All of them responded to immunotherapy, although 30% required polytherapy. CONCLUSIONS: The study of anti-MuSK antibodies defines a subgroup of patients, 34,61% in our series, with seronegative generalized myasthenia. This group is characterized by an homogenous clinical presentation with prevalent bulbar symptoms. The knowledge of the immunopathogenic mechanisms of anti-MuSK antibodies will allow a better understanding of both the variable response to acetylcholinesterase inhibitors and the absence of response to thymectomy in these patients.