Collateral circulation and outcome after basilar artery thrombolysis.

BACKGROUND AND PURPOSE: This study was undertaken to examine the relationship between collateral flow and outcome after local intraarterial thrombolytic treatment for basilar artery thrombosis. METHODS: Twenty-four patients with symptomatic basilar thrombosis were treated with intraarterial urokinase. Angiograms at the time of treatment were analyzed to characterize collateral flow. The number of posterior communicating arteries (PCoAs) and the degree of collateral filling of the basilar artery were then compared with symptom duration before treatment, with Glasgow Coma Scale (GCS) score at the time of treatment, with 90-day modified Rankin score, and with 90-day survival status. RESULTS: Of the 20 patients who had carotid artery injections at the time of the thrombolytic procedure, two had no PCoA, eight had one PCoA, and 10 had two PCoAs. Nine had no collateral opacification of the basilar artery, six had collateral opacification of the distal basilar artery, and five had collateral opacification of the distal and proximal basilar artery. Ninety-day survival was 38%; 25% of patients had good neurologic outcomes. No correlation was found between the number of PCoAs and symptom duration, pretreatment GCS score, survival, or neurologic outcome. Duration of symptoms before treatment was longer in patients with collateral flow to the basilar artery. Basilar artery collateral flow did not correlate with survival, but it did correlate with neurologic outcome for the 12 patients with middle or distal basilar artery thrombus in whom collateral flow to the basilar artery was assessed (83% with collateral flow had good neurologic outcomes, but only 17% without collateral flow had good outcomes). All six patients with proximal basilar artery thrombus in whom collateral flow was assessed died, independent of the collateral flow observed. CONCLUSION: In symptomatic acute basilar artery thrombosis, neurologic outcome was better after intraarterial thrombolysis in patients who had collateral filling of the basilar artery, except in cases of proximal basilar thrombosis. Patients with collateral filling of the basilar artery also tolerated longer symptom duration.

Intracranial pressure monitoring during intraarterial papaverine infusion for cerebral vasospasm.

PURPOSE: Intraarterial papaverine infusions are performed to reverse cerebral arterial vasospasm resulting from subarachnoid hemorrhage, but such infusions may lead to increases in intracranial pressure (ICP). This study was undertaken to determine when ICP monitoring is indicated during papaverine treatment. METHODS: Seventy-eight vessels were treated in 51 sessions in 28 patients with symptomatic vasospasm. ICP, papaverine doses, and infusion rates were recorded during treatment sessions. The procedural data, Hunt and Hess scores, Fisher grades, Glasgow Coma Scale scores, and ages for all subjects were reviewed and analyzed retrospectively. RESULTS: Baseline ICP ranged from 0 to 34 mm Hg. With typical papaverine doses of 300 mg per territory and infusion times ranging from 5 to 60 minutes per vessel, ICP increases above baseline during papaverine infusion ranged from 0 to 60 mm Hg. Significant (> or = 20 mm Hg) ICP increases during therapy were observed even in patients with low baseline ICP and with papaverine infused at the slowest rate. Patients with a baseline ICP of more than 15 mm Hg were much more likely to have significant ICP increases than were patients with a baseline ICP of 0 to 15 mm Hg. Hunt and Hess scores, Fisher grades, age, and Glasgow Coma Scale scores on admission and immediately before treatment did not correlate with ICP increases during papaverine infusion. Patients with ICP increases of more than 10 mm Hg during therapy were more likely to experience adverse clinical events than were patients with ICP increases of < or = 10 mm Hg. Reduction in the rate of papaverine infusion, or termination of infusion, resulted in reversal of drug-induced ICP elevation. CONCLUSION: ICP monitoring during intraarterial papaverine infusions for cerebral vasospasm is recommended for all patients and is particularly important for patients with elevated baseline ICP. Continuous ICP monitoring facilitates safe and time-efficient drug delivery.

Relationship between clot location and outcome after basilar artery thrombolysis.

PURPOSE: To identify factors that predict survival and good neurologic outcome in patients undergoing basilar artery thrombolysis. METHODS: Over a 42-month period, 20 of 22 consecutive patients with angiographic proof of basilar artery thrombosis were treated with local intraarterial urokinase. Brain CT scans, neurologic examinations, symptom duration, clot location, and degree of recanalization were analyzed retrospectively. RESULTS: Overall survival was 35% at 3 months. Survival in patients with only distal basilar clot was 71%, while survival in patients with proximal or midbasilar clot was only 15%. At 3 months, 29% of patients with distal basilar clot and 15% of patients with proximal or midbasilar clot had good neurologic outcomes (modified Rankin score of 0 to 2 and Barthel index of 95 to 100). Complete recanalization was achieved in 50% of patients; 60% of those survived and 30% had good neurologic outcomes. Of patients with less than complete recanalization, only 10% survived. Neither duration of symptoms before treatment (range, 1 to 79 hours), age (range, 12 to 83 years), nor neurologic status at the initiation of treatment (Glasgow Coma Scale score range, 3 to 15) predicted outcome. Pretreatment CT findings (positive or negative for related ischemic changes) did not predict outcome or hemorrhagic transformation. CONCLUSION: The single best predictor of survival after basilar thrombosis and intraarterial thrombolysis was distal clot location. Complete recanalization favored survival. Radiologically evident related infarctions, advanced age, delayed diagnosis, and poor pretreatment neurologic status did not predict poor outcome and therefore should not be considered absolute contraindications for intraarterial thrombolysis in patients with basilar artery thrombosis.

Altered vertebrobasilar flow in children: angiographic, MR, and MR angiographic findings.

PURPOSE: To characterize the clinical, MR, MR angiographic, and conventional angiographic findings in vertebrobasilar disease in children. METHODS: Eight children with posterior circulation ischemia and infarction had conventional spin-echo MR and MR angiography of the head and neck. Six patients had conventional angiography. RESULTS: Six patients had alteration of vertebral or basilar artery flow void on spin-echo images. MR angiography showed all six cases of angiographically proved vertebrobasilar dissection or occlusion despite overestimating the extent of arterial abnormality in two patients. In two patients the intracranial peripheral branch cutoff shown at angiography was correctly predicted on screening MR angiography. CONCLUSION: Posterior circulation infarction in children is usually secondary to traumatic injury to the vertebrobasilar circulation. MR and MR angiography noninvasively show vertebrobasilar flow disturbances and compare favorably with angiography in documenting dissection or occlusion of the vertebrobasilar circulation. MR angiography may obviate the need for invasive angiography in these children at diagnosis and during follow-up of anticoagulation therapy.

Prenatal diagnosis of central nervous system abnormalities.

Fetal anomalies have been the subject of innumerable publications both in the prenatal and neonatal literature. This has significantly increased in the last 10 years, mainly because of the advent of high-resolution ultrasound equipment and improvement of scanning techniques. In addition, guidelines issued by professional organizations involved in prenatal diagnosis have encouraged a more universal approach to the imaging and documentation of prenatal findings. The fetal central nervous system is the most frequently investigated organ system, mainly because of its easy accessibility and prominence even in the early stages of embryologic development. The biparietal diameter was the first fetal measurement to be widely used in determining gestational age. As investigators gained more experience, the appearance of ultrasound images achieved the resolution that allows direct comparisons with gross specimens and more recent sophisticated techniques of computed tomography and magnetic resonance imaging. Now endovaginal ultrasound can document early first trimester development and compare it to known embryologic landmarks. Interest in demonstrating the ultrasound counterpart of central nervous system structures in the early stages of development has resulted in a plethora of articles proving the unique ability of ultrasound in imaging the developing fetus. In view of all these developments, the beginning ultrasound specialist is faced with the challenge and responsibility not only of being familiar with the literature but also of the mastery of scanning techniques that allow accurate prenatal diagnosis. It is therefore helpful to review key developmental milestones in embryologic life and correlate them with the corresponding prenatal ultrasound appearance. In addition, the changing appearance of the developing fetus has created a need for a systematic approach in the evaluation of structures so routine protocols can be established. This has been the subject of other publications that allow the novice to draw from the cumulative experience of different centers around the world. It is important to pay attention to the specifics described in the literature when duplicating results in one's laboratory. The frustration of not being able to reproduce results is common, especially when technical limitations prevent imaging under ideal conditions. This is especially true in patients who are first seen in the later third trimester with no prior prenatal care.(ABSTRACT TRUNCATED AT 400 WORDS)