Contrast extravasation on computed tomographic angiography mimicking a basilar artery aneurysm in angiogram-negative subarachnoid hemorrhage: report of 2 cases.

BACKGROUND AND IMPORTANCE: Contrast extravasation on computed tomography angiography (CTA) is becoming more common, with increasing use of CTA for myriad intracranial vascular pathologies. This article describes the first 2 documented cases of contrast extravasation from a nonaneurysmal basilar artery source seen on CTA and discusses possible pathophysiologic mechanisms. CLINICAL PRESENTATION: We present 2 cases of diffuse atraumatic subarachnoid hemorrhage in which the CTA showed an abnormality in association with the basilar artery highly suggestive of a ruptured aneurysm. Follow-up digital subtraction angiography, however, was completely negative. Subsequent repeat digital subtraction angiography failed to reveal a vascular lesion. Both patients were treated for complications associated with SAH, but given the negative digital subtraction angiography, no intervention was performed. CONCLUSION: Because of the frequent use of CTA, contrast extravasation is an increasingly common observation. Physicians should be aware that basilar artery extravasation can mimic the appearance of an aneurysm.

Trends in the management of intracranial vascular malformations in the USA from 2000 to 2007.

Objective. To assess prevalence, clinical characteristics, trends in treatment pattern, and outcome in patients with intracranial vascular malformations (IVMs). Methods. Nationwide inpatient sample. Patients with the diagnosis of an IVM admitted to US hospitals from 2000 to 2007. Results. In 58,051 IVM-related admissions (detection rate 2.4/100,000 person-years; mean age 49 ± 17 years; 52% women) major diagnoses were intracranial hemorrhage (ICrH) in 15%, seizure 32%, ischemia 5%, and headache 9%. Procedures included surgery (13%), embolization (13%), radiation therapy (2%), aneurysm clipping (1%), and mechanical ventilation (6%). Ventilation and ICrH were associated with death (2%), whereas ventilation, ICrH, surgery, seizure, and ischemia were associated with unfavorable outcome (20%). IVM detection rate and hospital outcome remained stable over time, whereas mean age and comorbid diagnosis of cerebral ischemia increased (ICrH and seizure decreased). Conclusion. IVMs are infrequent and present in 1/6 patients with some form of ICrH. Overall, seizure is the dominant comorbid diagnosis (1/3 patients). IVMs are equally prevalent among race-ethnic groups and are increasingly detected later in life. The inpatient care of IVM patients results in death or discharge into specialized care in 1/5 patients.

Clinical utility of quantitative magnetic resonance angiography in the assessment of the underlying pathophysiology in a variety of cerebrovascular disorders.

BACKGROUND: Quantitative MRA (qMRA) is a relatively new technique that uses traditional time-of-flight and phase-contrast MRI to visualize extracranial and intracranial vascular anatomy and measure volumetric blood flow. We aimed to assess the clinical utility of qMRA in assessing the hypothesized pathophysiology (HP) in a range of cerebrovascular diseases. Moreover, we postulated that evaluation of the arterial waveforms, can improve the evaluation of the hypothesized pathophysiology by qMRA. METHODS: We reviewed studies from 10 patients who underwent qMRA examinations before and after their treatments. Two reviewers assessed the anatomy, volumetric flow rates and arterial waveforms for each vessel sampled and reached a consensus as to whether the above parameters supported the clinical diagnosis/hypothesized pathophysiology and the subsequent management. FINDINGS: All 20 qMRA studies were technically adequate. qMRA supported the HP in all 10 patients as determined by abnormal volumetric flow values in the affected vessels before treatment and by the correction of these abnormal values in the patients whose treatment was successful. Each of our five patients with occlusive disease/vasoconstriction demonstrated evidence of dampening of the arterial waveforms distally to the narrowed artery (parvus-tardus phenomenon). The parvus-tardus effect disappeared after treatment. CONCLUSION: qMRA is unique in combining time-of-flight MRA in a complementary manner with phase-contrast MRA to obtain volumetric flow values and potentially important physiologic information from arterial waveform analysis in patients with a range of cerebrovascular diseases during the course of a single MR examination.

The ARUBA trial: current status, future hopes.

BACKGROUND AND PURPOSE: Report on the status of an on-going National Institutes of Neurological Disorders and Stroke (NINDS)-supported clinical trial of management of unbled brain arteriovenous malformations. SUMMARY OF REVIEW: Begun in April 2007 with 3 centers, the trial has grown to 65 centers, and has randomized 124 patients through mid-June 2010 en route to the planned 400. The current literature continues to support the rationale for the trial. CONCLUSIONS: ARUBA is steadily approaching its monthly randomization goals and has already reached the number needed to test the maximum published interventional complication rates against the minimum hemorrhage rates for natural history.

De novo formation of large arteriovenous shunting and a vascular nidus mimicking an arteriovenous malformation within an anaplastic oligodendroglioma: treatment with embolization and resection.

The authors report the de novo occurrence and treatment of an arteriovenous lesion within an anaplastic oligodendroglioma in a patient with previously unremarkable brain imaging. Intracranial arteriovenous malformations (AVMs) are believed to be congenitally acquired lesions, and their association with brain neoplasms is extremely rare. Diagnostic imaging revealed a mass lesion with large arteriovenous shunts and a vascular nidus mimicking a true AVM. Histological and immunohistochemical testing showed an anaplastic oligodendroglioma mixed with an AVM. The clinical, radiological, and operative data are reviewed, as are the histopathological findings. To the authors' knowledge this is the first case of de novo occurrence of an arteriovenous lesion with large shunts and a vascular nidus within an anaplastic oligodendroglioma.

Aneurysmal rupture during coiling: low incidence and good outcomes at a single large volume center.

OBJECTIVE: To study the incidence and clinical outcomes of intraoperative aneurysm rupture (IOR) during endovascular coil embolization at a single large volume center and to review the literature on this subject to determine whether IOR rupture rate and mortality correlate with volume of aneurysms treated at a given center and years since the institution of Guglielmi detachable coils as a treatment modality. METHODS: We reviewed the aneurysm database at the Center for Endovascular Surgery since its inception (1997-2003) and reviewed 600 consecutively treated intracranial aneurysms in which coiling was attempted. All patients who sustained an IOR were studied. Procedural and follow-up angiograms as well as clinical outcomes were retrospectively reviewed. A literature review was conducted. RESULTS: Six patients (1.0%) experienced IOR (1.4% in acutely ruptured lesions, 0% in unruptured). All six had presented with diffuse subarachnoid hemorrhage (Fisher Grade 3) and in good clinical grade (Hunt & Hess Grades 1-3). One patient was rendered permanently disabled secondary to delay in controlling the IOR. All others were neurologically unchanged. A review of the literature revealed a trend in correlation between volume of aneurysms treated and IOR rate; no statistically significant correlation was found between volume of aneurysms treated or years since the introduction of GDC technology and IOR rates or mortality. CONCLUSION: IOR remains a serious risk of endosaccular coiling of intracranial aneurysms, with aneurysms presenting with subarachnoid hemorrhage at greater risk for this complication. This risk can be minimized with very low associated morbidity and mortality (incidence 1%, 17% morbidity, 0% mortality at our institution).

Wingspan stenting of symptomatic extracranial vertebral artery stenosis and perioperative evaluation using quantitative magnetic resonance angiography: report of two cases.

The best management strategy for symptomatic vertebrobasilar ischemia is currently not well-defined. Noninvasive Optimal Vessel Analysis (NOVA, VasSol, Inc.) is computer software that, using quantitative magnetic resonance (MR) angiography technology, represents the only commercially available means of noninvasively measuring blood flow within the human vasculature. The author used quantitative MR angiography to study cerebral blood flow in 2 patients who underwent angioplasty and stenting for medically refractory extracranial cervical vertebral artery (VA) stenosis using the recently Food and Drug Administration-approved WingSpan stent (Boston Scientific, Target). WingSpan stents were successfully placed after balloon angioplasty in both patients without complications. At the 5-month clinical follow-up examination, 1 patient was symptom free and the other had had a possible transient ischemic attack without sequelae. The WingSpan stent may represent an alternative management scheme for symptomatic vertebrobasilar ischemia from extracranial VA stenosis. Quantitative MR angiography can readily measure blood flow in the vertebrobasilar system, and these values correlated with the angiographic outcomes in the 2 patients treated in the present study.

Endovascular treatment of acute ischaemic stroke.

The emphasis of treatments for acute ischaemic stroke during the past two decades has been on revascularisation. Endovascular treatment is a promising alternative for patients who are ineligible for standard intravenous thrombolytic therapy; however, its use is limited by the few randomised trials reported and the small number of practising neurointerventionalists. Although data are still being collected, important progress has been made. In this Review, we summarise the findings of the major clinical trials of endovascular treatment, and show that endovascular treatment of acute ischaemic stroke is a therapeutic option for patients who are disqualified from or do not improve on treatment with intravenous alteplase. Moreover, the American Heart Association has expanded its guidelines to include endovascular stroke therapies as a treatment option.

Reliability of S100B in predicting severity of central nervous system injury.

S100B is a protein biomarker that reflects CNS injury. It can be measured in the CSF or serum with readily available immunoassay kits. The excellent sensitivity of S100B has enabled it to confirm the existence of subtle brain injury in patients with mild head trauma, strokes, and after successful resuscitation from cardiopulmonary arrest. The extent of S100B elevation has been found to be useful in predicting clinical outcome after brain injury. Elevations of S100B above certain threshold levels might be able to reliably predict brain death or mortality. A normal S100B level reliably predicts the absence of significant CNS injury. The specificity of S100B levels as a reflection of CNS injury is compromised by the findings that extra-cranial injuries can lead to elevations in the absence of brain injury. This potential problem can most likely be avoided by measuring serial S100B levels along with other biomarkers and carefully noting peripheral injuries. Serum markers GFAP and NSE are both more specific for CNS injury and have little to no extra-cranial sources. Sustained elevations of S100B over 24 h along with elevations of GFAP and NSE can more reliably predict the extent of brain injury and clinical outcomes. In the future, S100B measurements might reliably predict secondary brain injury and enable physicians to initiate therapeutic interventions in a timelier manner. S100B levels have been shown to rise hours to days before changes in ICP, neurological examinations, and neuroimaging tests. S100B levels may also be used to monitor the efficacy of treatments.

Neurointerventional treatment of vasospasm.

OBJECTIVES: To review the historical development and current status of endovascular techniques used in the treatment of symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. METHODS: This article summarizes the relevant literature on neurointerventional therapy for vasospasm, namely instillation of intraarterial medication (papaverine, nicardipine, verapamil) and transluminal balloon angioplasty. The authors synthesize the available literature with their own experience using the various endovascular modalities to treat vasospasm at high volume cerebrovascular centers. TECHNIQUE: Indications for the use of neurointerventional therapy as well as a summary of the technique for transluminal angioplasty to treat vasospasm as employed by the authors is described. DISCUSSION: Neurointerventional treatment of vasospasm following aneurysmal hemorrhage has been proven to be a safe and successful technique for those patients suffering symptomatic vasospasm refractory to medical management. The techniques contunue to undergo refinement as endovascular technology advances. We currently favor the use of balloon angioplasty over intraarterial antispasmotics due to the increased durability and long-lasting effects of the former and lower risk profile.

Successful emergent angioplasty of neurosarcoid vasculitis presenting with strokes.

BACKGROUND: Sarcoidosis is a systemic disease with neurologic involvement in approximately 5% of cases. Ischemic events related to neurosarcoid vasculitis are rare. We report the successful treatment of symptomatic neurosarcoid vasculitis with angioplasty. CASE DESCRIPTION: A 41-year-old African American with a diagnosis of neurosarcoid presented with aphasia and right-sided weakness. He was treated medically with antiplatelet agents, heparinization, and hypertensive therapy. Despite this treatment, he experienced clinical worsening and radiographic extension of his infarcts. He underwent successful angioplasty of a severe focal stenosis of the left middle cerebral artery. After the procedure, he experienced marked improvement in his symptoms and at follow-up continues to improve. CONCLUSIONS: We report the angiographic demonstration of neurosarcoidosis with large vessel changes and resultant strokes and its successful treatment with balloon angioplasty.

Transarterial embolization of vein of Galen malformations: the use of magnetic resonance imaging noninvasive optimal vessel analysis to quantify shunt reduction. Report of two cases.

In patients with vein of Galen malformations, high-flow shunting decreases cerebral perfusion. By reducing or eliminating these shunts, transarterial embolization can improve cerebral perfusion and clinical outcomes. Quantifying pre- and postembolization shunt blood flow may help determine the optimal timing and efficacy of embolization and may provide prognostic information. The authors used magnetic resonance imaging noninvasive optimal vessel analysis as a novel modality to measure volumetric blood flow through vein of Galen malformation shunts in a neonate and an infant before and after transarterial embolization.

Cystic dilation of the conus ventriculus terminalis presenting as an acute cauda equina syndrome relieved by decompression and cyst drainage: case report.

OBJECTIVE AND IMPORTANCE: The ventriculus terminalis of the conus, or "fifth ventricle" refers to the ependymal-lined space in the middle of the conus that is present in childhood and whose persistence into adulthood is rare. A number of cases of cystic dilatation of the ventriculus terminalis have been described in adulthood. Patients tend to present with either pain alone or gradually progressive conus or cauda equina syndromes with varying degrees of recovery after cyst drainage. Presentation with an acute cauda equina syndrome and its successful surgical management has not been previously reported. CLINICAL PRESENTATION: A 57-year-old woman experienced back pain and bilateral sciatica ascribed to diabetic neuropathy for 2 years. Over a 24-hour period she developed bilateral lower extremity weakness, saddle anesthesia, and bowel and bladder incontinence. Lumbosacral magnetic resonance imaging demonstrated a large cystic dilatation of the ventriculus terminalis. INTERVENTION: She was taken for emergency surgical decompression and cyst drainage. Immediately after surgery, she experienced significant increase in lower extremity strength and has since regained continence. CONCLUSION: Cystic dilation of the ventriculus terminalis should be part of the differential diagnosis for a cauda equina syndrome; surgical decompression with simple cyst drainage can result in excellent clinical results.

Aneurysmal rupture during coiling: low incidence and good outcomes at a single large volume center.

OBJECTIVE: To study the incidence and clinical outcomes of intraoperative aneurysm rupture (IOR) during endovascular coil embolization at a single large volume center and to review the literature on this subject to determine whether IOR rupture rate and mortality correlate with volume of aneurysms treated at a given center and years since the institution of Guglielmi detachable coils as a treatment modality. METHODS: We reviewed the aneurysm database at the Center for Endovascular Surgery since its inception (1997-2003) and reviewed 600 consecutively treated intracranial aneurysms in which coiling was attempted. All patients who sustained an IOR were studied. Procedural and follow-up angiograms as well as clinical outcomes were retrospectively reviewed. A literature review was conducted. RESULTS: Six patients (1.0%) experienced IOR (1.4% in acutely ruptured lesions, 0% in unruptured). All six had presented with diffuse subarachnoid hemorrhage (Fisher Grade 3) and in good clinical grade (Hunt & Hess Grades 1-3). One patient was rendered permanently disabled secondary to delay in controlling the IOR. All others were neurologically unchanged. A review of the literature revealed a trend in correlation between volume of aneurysms treated and IOR rate; no statistically significant correlation was found between volume of aneurysms treated or years since the introduction of GDC technology and IOR rates or mortality. CONCLUSION: IOR remains a serious risk of endosaccular coiling of intracranial aneurysms, with aneurysms presenting with subarachnoid hemorrhage at greater risk for this complication. This risk can be minimized with very low associated morbidity and mortality (incidence 1%, 17% morbidity, 0% mortality at our institution).

Pediatric nonvertebral paraspinal arteriovenous fistulas along the segmental nerve: clinical, imaging, and therapeutic considerations.

OBJECT: The authors characterize the clinical presentation and imaging features of paraspinal nonvertebral arteriovenous fistulas (AVFs) along the segmental nerve and describe their endovascular treatment. METHODS: The authors undertook a retrospective review of medical records, imaging, and treatment of patients with endovascular problems spanning the period from 1985 to 2003. Five pediatric patients (2-3 years of age) received diagnoses of nonvertebral paraspinal AVFs along the segmental nerve. All patients presented with an incidentally discovered continuous murmur over the paraspinal or parasternal regions. All patients were neurologically intact; two patients had cardiomegaly. The AVF was found in the midthoracic level in four patients and at L-3 in one patient. All AVFs were high-flow single-hole fistulas at the neural foramen with venous drainage into paraspinal and epidural veins but without intradural reflux. All fistulas were endovascularly occluded in the same session as diagnostic angiography took place. The fistula was completely occluded, with detachable coils in one case and with N-butyl-cyanoacrylate (NBCA) in four cases. Before NBCA injection, the flow through the fistula was decreased either by placing coils distal to the fistula or by inflating a balloon proximally. No signs of recanalization appeared on short-term follow-up magnetic resonance imaging in all patients. All patients remained neurologically intact at the last available follow-up session (mean 6 years). CONCLUSIONS: Nonvertebral paraspinal AVFs along the segmental nerve are specific disease entities seen in children presenting with bruit and cardiomegaly. Endovascular embolization should be the treatment of choice for this rare disease.

Multiple cerebral aneurysms in a neonate: occlusion and rupture.

Aneurysmal subarachnoid hemorrhage in a neonate is exceedingly uncommon. The authors report the case of a neonate with a large anterior communicating artery aneurysm, accessory left middle cerebral artery aneurysm, and left internal carotid artery (ICA) fusiform aneurysm. The neonate suffered from occlusion of the left ICA and aneurysm rupture. The large aneurysm was treated with detachable coils and the patient made a significant recovery. Of the 15 case reports of cerebral aneurysms in neonates that have been published, none has contained a description of multiple aneurysms or a discussion of endovascular treatment.