The effect of anesthesia on hemodynamics and outcome of patients undergoing thrombectomy after acute ischemic stroke: a retrospective analysis.

BACKGROUND: Anesthesia during thrombectomy remains a matter of debate. We retrospectively investigated the influence of intraprocedural blood pressure and type of anaesthetic agent on 3-month functional outcome and mortality in stroke patients undergoing mechanical thrombectomy under general anesthesia in a single center study. METHODS: All patients suffering from stroke who presented between January 2019 and July 2021 at Ziekenhuis Oost-Limburg Genk, Belgium and who received thrombectomy were included. Patient's characteristics and outcome data had been collected for benchmarking. Detailed perioperative data were exported from the electronic anesthesia records and clinically validated. Patients were stratified by peri-operative presence of hypotension (MAP < 65 mmHg at any time point) versus no-hypotension (MAP ≥ 65 mmHg). RESULTS: All 98 patients received mechanical thrombectomy under general anesthesia. Thirty-six percent (n = 35) was hypotensive peri-operatively at any time point. Proportion of sevoflurane use was higher in non-hypotensive patients compared to hypotensive patients (73% (n = 45) vs. 51% (n = 18), p = 0.04). Peri-operative use of vasopressors was higher in the hypotensive group compared to non-hypotensive (88% (n = 30) vs. 63% (n = 39), p = 0.008). Proportion of patients with good functional outcome at 3 months (mRS 0-2) was higher in non-hypotensive patients compared to hypotensive patients 44% (n = 27) vs. 24% (n = 8), p < 0.05. 90-day mortality was lower in non-hypotensive patients compared to hypotensive patients 21% (n = 13) vs. 43% (n = 15), (p = 0.02). CONCLUSION: Patients who are hypotensive at any given time during thrombectomy under general anesthesia may have worse neurological outcome compared to non-hypotensive patients. The best anaesthetic management for mechanical thrombectomy needs to be clarified prospectively in large multicenter studies.

The Woven EndoBridge for unruptured intracranial aneurysms: Results in 95 aneurysms from a single center.

BACKGROUND AND PURPOSE: The Woven EndoBridge (WEB) is an intrasaccular flowdisruptor that is increasingly used for the treatment of (wide-necked) aneurysms. We present our experience with the WEB for unruptured aneurysms. MATERIALS AND METHODS: Between April 2014 and August 2019, 93 patients with 95 unruptured aneurysms were primarily treated with the WEB. There were 69 women and 24 men, mean age 61 years (median 58, range 37-80). RESULTS: Of 95 aneurysms, 86 had been discovered incidentally, 3 were symptomatic and 6 were additional to another ruptured aneurysm. Location was anterior communicating artery 33, middle cerebral artery 29, basilar tip 19, carotid tip 8, posterior communicating artery 4, posterior inferior cerebellar artery 1, superior cerebellar artery 1. Mean aneurysm size was 6 mm (median 6, range 3-13 mm).In one aneurysm additional coils were used and in another, a stent was placed. There was one procedural rupture without clinical sequelae. There were two thrombo-embolic complications leading to permanent deficit in one patient (mRS 2). Morbidity rate was 1.0% (1 of 93, 95%CI 0.01-6.5%) and mortality was 0% (0 of 93, 95%CI 0.0-4.8%). Angiographic follow-up at six months was available in 85 patients with 87 aneurysms (91%). Of 87 aneurysms, 68 (78%) were completely occluded, 14 (16%) had a neck remnant and 5 were incompletely occluded. Four aneurysms were retreated. Retreatment rate was 4.5% (4 of 87, 95%CI 1.7-13.6%). CONCLUSION: WEB treatment of unruptured aneurysms is safe and effective. Additional devices are needed only rarely and retreatment at follow-up is infrequent.

The external carotid artery as a rare feeder of a spinal dural arteriovenous fistula causing cervical myelopathy: A review of the literature.

Introduction: A causal relationship between SDAVF's and cervical myelopathy is exceedingly rare. 1-2% of these lesions are located at the craniocervical junction of which 12% are caused by arterial feeders from the external carotid artery. A correct diagnosis can be challenging with a high rate of initial misdiagnosis. Research question: Which aspects constitute the most important potential pitfalls in the diagnostic workup and treatment of SDAVF's with feeders from the external carotid artery causing cervical myelopathy? Material and methods: We performed a PRISMA-guided review of the literature in which fourteen articles were included. We illustrate the diagnostic hazards through one of our own cases. Results: SDAVF's at the cervical segment contain unique clinical and radiographic characteristics which differ from those elsewhere. Cervical myelopathy is caused by a SDAVF in 2.3% of cases. Pitfalls are numerous and diagnosis can be challenging, due to a broad differential diagnosis, potential isolated lower extremity involvement and absence of spinal cord edema on MRI. MR-alterations not always correlate with fistula localization. Discussion and conclusion: A SDAVF should be part of the differential diagnosis in patients with subacute tetraparesis. When MRI shows signal alterations in combination with enlarged perimedullary vessels, a SDAVF should be suspected. Spinal angiography should include the vertebrobasilar system, as well as the internal and external carotid arteries. Early and adequate occlusion by means of an endovascular or neurosurgical approach of the draining radicular veins should be pursued. A multidisciplinary approach is key in the diagnostic workup and treatment of these patients.

p64 flow diverter: Results in 108 patients from a single center.

BACKGROUND AND PURPOSE: Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. MATERIALS AND METHODS: We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. RESULTS: Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1-6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. CONCLUSION: The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern.

Transarterial embolization of peripheral arteriovenous malformations with ethylenevinyl alcohol copolymer - feasibility, technical outcomes, and clinical outcomes.

BACKGROUND: The technical and clinical outcomes of catheter-directed embolization for peripheral arteriovenous malformations (AVM) using Onyx® (ethylene-vinyl alcohol copolymer) are not well documented. The purpose of this study was to retrospectively assess the safety, technical outcomes and clinical outcomes of catheter-directed Onyx® embolisation for the treatment of symptomatic peripheral AVMs. PATIENTS AND METHODS: Demographics, (pre-)interventional clinical and radiological data were assessed. Follow-up was based on hospital medical records and telephone calls to the patients' general practitioners. Radiological success was defined as complete angiographic eradication of the peripheral AVM nidus. Clinical success was defined as major clinical improvement or complete disappearance of the initial symptoms. RESULTS: 25 procedures were performed in 22 patients. The principal indications for treatment were pain (n = 10), limb swelling (n = 6), recurrent bleeding (n = 2), tinnitus (n = 3), and exertional dyspnoea (n = 1). Complete radiological success was obtained in eight patients (36 %); near-complete eradication of the nidus was achieved in the remaining 14 patients. Adjunctive embolic agents were used in nine patients (41 %). Clinical success was observed in 18 patients (82%). Major complications were reported in two patients (9 %). During follow-up, seven patients (32 %) presented with symptom recurrence, which required additional therapy in three patients. CONCLUSIONS: Catheter-directed embolisation of peripheral AVMs with Onyx® resulted in major clinical improvement or complete disappearance of symptoms in the vast majority of patients, although complete angiographic exclusion of the AVMs occurred in only a minority of patients.

Anatomical variations and pre-operative imaging technique concerning the anterolateral thigh flap: guiding the surgeon.

The anterolateral thigh (ALT) flap has widespread use throughout the body because of the many engineering options. The ALT has a complex local vasculature, which can be of importance for the surgical approach. In general, the flap receives its perfusion from branches of the lateral circumflex femoral artery (LCFA). The LCFA, however, has a large anatomic variance. CT angiography can guide the surgeon in the selection of the most suitable site and aid in the surgical approach.

Prostatic biopsy-related rectal bleeding refractory to medical and endoscopic therapy definitively managed by catheter-directed embolotherapy: a case report.

INTRODUCTION: Ultrasound-guided transrectal prostatic biopsy is generally a well-tolerated radiological technique with low overall complication ratio. If post-biopsy rectal bleeding occurs, conservative management is effective in the majority of cases. Endoscopic or interventional treatment is rarely required. CASE PRESENTATION: We report the case of an 82-year-old white man presenting with massive rectal bleeding after ultrasound-guided prostatic biopsy. Medical and endoscopic management were not effective. Angiographic evaluation revealed a prostatic arteriovenous fistula, and definitive treatment was provided in the form of catheter-directed superselective embolotherapy. CONCLUSION: Transrectal prostatic biopsy may be associated with massive rectal bleeding. Transcatheter embolotherapy can be effective in definitively stopping the bleeding.

CT diagnosis of a post-embolization ischemic diverticulitis of Meckel.

A 23-year-old man presented with hypovolemic shock due to a lower gastrointestinal bleeding. Radiological and endoscopic investigation did not reveal the bleeding site. Emergency visceral angiography showed contrast extravasation at a right-sided branch of the superior mesenteric artery (SMA). Embolization of the bleeding point was performed, resulting in bleeding cessation. One week later, the patient presented with a new episode of moderate anal blood loss associated with diffuse abdominal pain. Computed tomography (CT) revealed an ischemic small bowel diverticulum that was treated by a laparoscopically-assisted segmental small bowel resection. Intraoperative and pathologic analysis confirmed a post-embolization ischemic diverticulitis of Meckel.

IgG4-related systemic disease affecting the parotid and submandibular glands: magnetic resonance imaging features of IgG4-related chronic sclerosing sialadenitis and concomitant lymphadenitis.

BACKGROUND: IgG4-related systemic disease (IgG4-RSD) is a recently recognised fibroinflammatory condition, characterized by a tissue infiltration and/or enlargement and typical histopathological findings. METHODS AND RESULTS: We report on a 73-year-old male with bilateral preauricular swelling and a remote history of unexplained systemic disease. Magnetic resonance imaging showed enlargement of all major salivary glands and cervical lymph node due to a tissue infiltration with marked enhancement and restricted diffusion. Elevated serum IgG4 levels and histopathological findings on an excisional lymph node biopsy were consistent with IgG4-RSD. CONCLUSION: Magnetic resonance imaging seems to be a useful tool to support the diagnosis of IgG4-related systemic disease of salivary glands.