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1.
Eur J Neurol ; 31(6): e16256, 2024 Jun.
Article in English | MEDLINE | ID: mdl-38409874

ABSTRACT

BACKGROUND AND PURPOSE: The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. METHODS: SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. RESULTS: Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage  among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). CONCLUSIONS: No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.


Subject(s)
Endovascular Procedures , Fibrinolytic Agents , Stents , Thrombectomy , Tissue Plasminogen Activator , Humans , Male , Female , Aged , Middle Aged , Fibrinolytic Agents/administration & dosage , Tissue Plasminogen Activator/administration & dosage , Tissue Plasminogen Activator/therapeutic use , Thrombectomy/methods , Endovascular Procedures/methods , Carotid Stenosis/surgery , Aged, 80 and over , Administration, Intravenous , Ischemic Stroke/surgery , Ischemic Stroke/drug therapy , Treatment Outcome , Thrombolytic Therapy/methods
2.
Radiol Case Rep ; 18(11): 4123-4129, 2023 Nov.
Article in English | MEDLINE | ID: mdl-37745771

ABSTRACT

Spinal dural arteriovenous fistulas (SDAVF) are the most common vascular malformations affecting the spinal cord. It is infrequently encountered in clinical practice and is believed to be acquired, predominantly affecting middle-aged and elderly men with unknown etiology. It is usually misdiagnosed despite presenting with conventional clinical findings and radiological features. Insidious onset of myelopathic findings is seen in addition to pathognomonic findings of cord edema and intrathecal flow voids on MRI. We present a case of SDAVF that was missed by the treating orthopedic surgeon and underwent spinal decompression with subsequent persistence of myelopathic symptoms. Angiography is required to confirm the diagnosis location of the fistula. Treatment is with embolization using liquid embolic agents or surgical through ligation of the draining vein. Endovascular techniques are minimally invasive, safe, and effective. Knowledge of the characteristics and advantages/disadvantages of each agent helps in planning and appropriate selection of agents for the patient. We report successful embolization with improved clinical outcomes for the patient using precipitating hydrophobic injectable liquid (PHIL) embolic agent. The outcome and prognosis of SDAVF depend on the duration of symptoms, severity of neurological symptoms, and successful occlusion of the fistulous draining vein. Awareness of this rare condition amongst clinicians and radiologists, would enable an earlier diagnosis and avoid morbid outcomes of this treatable condition.

3.
J Stroke Cerebrovasc Dis ; 32(2): 106910, 2023 Feb.
Article in English | MEDLINE | ID: mdl-36473397

ABSTRACT

OBJECTIVES: The optimal endovascular treatment for tandem occlusion in anterior circulation ischaemic stroke remains unknown. The aim of this study was to examine how the aetiology of carotid pathology, dissection versus atherothrombosis, affects clinical outcomes. MATERIALS AND METHODS: Data was obtained from prospectively collected registries from two stroke centres between April 2016 and December 2020. Tandem cases with complete cervical internal carotid artery (ICA) occlusion or near-total occlusion (≥90% stenosis) were included. Patients were divided into two groups based on carotid pathology: dissection versus atherothrombosis. RESULTS: A total of 134 patients were included: 36 were dissection and 98 were atherothrombosis. The dissection group had better clinical outcomes compared to the atherothrombosis group, although after adjusting for age and stroke risk factors differences were non-significant. In the non-stented cohort, the dissection patients achieved a better outcome (modified Rankin scale 0-2) than atherothrombotic patients (57% vs. 34%, p=0.04) at 90-days. CONCLUSION: Dissection-related tandem occlusions appear to have different clinical features from atherothrombotic tandem occlusions which suggests different management strategies are needed.


Subject(s)
Arterial Occlusive Diseases , Brain Ischemia , Carotid Artery Diseases , Endovascular Procedures , Stroke , Humans , Stroke/diagnostic imaging , Stroke/etiology , Brain Ischemia/complications , Treatment Outcome , Endovascular Procedures/adverse effects , Carotid Artery, Internal/diagnostic imaging , Arterial Occlusive Diseases/complications , Thrombectomy/adverse effects , Carotid Artery Diseases/complications , Retrospective Studies , Stents
4.
J Stroke Cerebrovasc Dis ; 25(1): e1-3, 2016 Jan.
Article in English | MEDLINE | ID: mdl-26599977

ABSTRACT

A 69-year-old gentleman with metastatic esophageal adenocarcinoma presented with acute abdominal pain to the emergency medicine department and subsequently developed an acute left hemiplegia while in the resuscitation unit. An unenhanced computed tomography (CT) scan of the head showed right frontal cerebral gas emboli while an unenhanced CT scan of the abdomen and pelvis showed extensive portal venous gas and pneumatosis intestinalis, presumed secondary to bowel infarction.


Subject(s)
Embolism, Air/etiology , Infarction/complications , Intestine, Small/blood supply , Intracranial Embolism/etiology , Postoperative Complications/etiology , Abdomen, Acute , Adenocarcinoma/complications , Adenocarcinoma/secondary , Adenocarcinoma/surgery , Aged , Embolism, Air/diagnostic imaging , Esophageal Neoplasms/pathology , Esophageal Neoplasms/surgery , Esophagectomy , Fatal Outcome , Frontal Lobe/blood supply , Frontal Lobe/diagnostic imaging , Hemiplegia/etiology , Humans , Ileostomy , Intracranial Embolism/diagnostic imaging , Male , Mesenteric Veins , Peritoneal Neoplasms/complications , Peritoneal Neoplasms/secondary , Portal Vein , Postoperative Complications/diagnostic imaging , Radiography
5.
J Neurointerv Surg ; 8(5): e18, 2016 May.
Article in English | MEDLINE | ID: mdl-25953859

ABSTRACT

The WEB is an endovascular flow-disrupting device used in treating wide-necked intracranial aneurysms. Although the device is available in varying sizes, large aneurysms pose a challenge with the need for custom-made devices. We describe the use of coils as an adjunct to the WEB device in successfully treating large aneurysms in two patients, one with an acutely ruptured aneurysm. This novel technique of jailing a microcatheter, deploying the WEB and then coiling the aneurysm saves the need for intracranial stenting, thereby avoiding the need for antiplatelet therapy, which is of benefit in the setting of acute aneurysm rupture.


Subject(s)
Catheterization, Peripheral/methods , Embolization, Therapeutic/methods , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/therapy , Stents , Angiography, Digital Subtraction , Female , Femoral Artery/diagnostic imaging , Humans , Male , Middle Aged
6.
J Neurointerv Surg ; 8(6): 596-602, 2016 Jun.
Article in English | MEDLINE | ID: mdl-25994938

ABSTRACT

BACKGROUND: Liquid embolic agents are the preferred embolic material in endovascular treatment of pial and brain arteriovenous malformations and dural arteriovenous fistulas (DAVFs). There is little choice available in interventional neuroradiology practice other than two of the most commonly used liquid embolic agents-n-butyl cyanoacrylate and the Onyx liquid embolic system (ev3 Neurovascular, Irvine, California, USA). PHIL (Precipitating Hydrophobic Injectable Liquid) (Microvention, Inc California, USA) is a new liquid embolic agent, CE marked and available for clinical use in Europe. OBJECTIVE: To present our preliminary experience using PHIL in treating cranial and spinal DAVFs. METHODS: Between September 2014 and January 2015, eight patients, with five cranial DAVFs and three spinal DAVFs were treated with PHIL as the sole embolic agent used with intent to cure. Clinical presentation, location of DAVF, Borden type, fluoroscopic time, radiation dose, procedural time, injecting microcatheter used, volume of PHIL injected, complications, immediate angiographic data, premorbid and discharge modified Rankin Scale score, and any neurologic deficits were included in the analysis. RESULTS: Seven patients were successfully treated with complete angiographic exclusion of the fistula in a single sitting. Treatment failed in one patient where only suboptimal microcatheter positioning could be achieved and PHIL failed to penetrate the fistula's nidus. Venous penetration was achieved in all other patients except one with a small fistula, but with adequate fistula penetration by the embolic material. No other technical complication or neurologic deterioration occurred in any of the patients. CONCLUSIONS: PHIL liquid embolic agent appears to be an excellent alternative embolic material with certain advantages compared with other available liquid embolic agents. Further studies are required to fully evaluate its safety and efficacy.


Subject(s)
Cardiovascular Agents/administration & dosage , Central Nervous System Vascular Malformations/therapy , Dimethyl Sulfoxide/administration & dosage , Embolization, Therapeutic , Intracranial Arteriovenous Malformations/therapy , Female , Humans , Male , Middle Aged , Polymers/administration & dosage
7.
BMJ Case Rep ; 20152015 May 02.
Article in English | MEDLINE | ID: mdl-25935916

ABSTRACT

The WEB is an endovascular flow-disrupting device used in treating wide-necked intracranial aneurysms. Although the device is available in varying sizes, large aneurysms pose a challenge with the need for custom-made devices. We describe the use of coils as an adjunct to the WEB device in successfully treating large aneurysms in two patients, one with an acutely ruptured aneurysm. This novel technique of jailing a microcatheter, deploying the WEB and then coiling the aneurysm saves the need for intracranial stenting, thereby avoiding the need for antiplatelet therapy, which is of benefit in the setting of acute aneurysm rupture.


Subject(s)
Embolization, Therapeutic/instrumentation , Intracranial Aneurysm/therapy , Microsurgery , Blood Vessel Prosthesis , Cerebral Angiography , Embolization, Therapeutic/methods , Female , Humans , Intracranial Aneurysm/pathology , Male , Middle Aged , Prosthesis Design , Treatment Outcome
8.
Curr Probl Diagn Radiol ; 43(1): 35-53, 2014.
Article in English | MEDLINE | ID: mdl-24290201

ABSTRACT

Percutaneous vascular embolization is one of the major applications of interventional radiology. A wide variety of embolization agents are currently available for clinical use. The interventional radiologist needs to be up to date with the newer and different types of embolic agents available along with their biopharmaceutical characteristics, strengths, and weaknesses that have been reviewed. For the purpose of this review, we have classified embolization agents into mechanical occlusion devices, particulate agents, and liquid agents, with some degree of overlap between some of the agents.


Subject(s)
Angioplasty, Balloon, Coronary , Embolization, Therapeutic , Hemoptysis/therapy , Radiology, Interventional , Sclerosing Solutions/therapeutic use , Angioplasty, Balloon, Coronary/methods , Embolization, Therapeutic/instrumentation , Embolization, Therapeutic/trends , Female , Gelatin , Hemoptysis/diagnostic imaging , Humans , Male , Microspheres , Polyvinyls , Radiography , Radiology, Interventional/methods , Tissue Adhesives/therapeutic use
10.
Curr Probl Diagn Radiol ; 42(4): 135-40, 2013.
Article in English | MEDLINE | ID: mdl-23795992

ABSTRACT

Pelvic congestion syndrome (PCS) is an important cause of chronic pelvic pain in female patients. Chronic pelvic pain, defined as lower abdominal or pelvic pain for a duration of 6 months or more, causes significant morbidity and results in a large number of diagnostic laparoscopies. It is of utmost importance to identify treatable causes of chronic pelvic pain, one of which is PCS. The etiology, clinical features, investigations, and treatment options in PCS have been discussed in this paper.


Subject(s)
Diagnostic Imaging , Ovary/blood supply , Pelvic Pain/diagnosis , Pelvic Pain/etiology , Pelvic Pain/therapy , Varicose Veins/complications , Varicose Veins/diagnosis , Varicose Veins/therapy , Chronic Disease , Female , Humans , Pain Measurement , Syndrome
11.
J Vasc Interv Radiol ; 21(2): 175-7, quiz 178, 2010 Feb.
Article in English | MEDLINE | ID: mdl-20123204

ABSTRACT

Hypercholesterolemia is an important and easily modifiable risk factor for peripheral arterial disease (PAD), but is frequently not adequately addressed by vascular interventionists. Patients with PAD often have extensive atherosclerotic disease elsewhere and have a 1-year mortality rate as high as 20%, mainly from cardiovascular events. This case discussion briefly addresses the evidence for treating hypercholesterolemia in this subgroup of patients. Statins not only lower cholesterol, but also are antiinflammatory, antiproliferative, and antithrombogenic, and improve endothelial function. Current guidelines are reviewed and an approach to initiation of statins and their management is discussed.


Subject(s)
Angioplasty, Balloon , Arterial Occlusive Diseases/therapy , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Hypercholesterolemia/drug therapy , Intermittent Claudication/therapy , Angioplasty, Balloon/instrumentation , Arterial Occlusive Diseases/diagnostic imaging , Arterial Occlusive Diseases/etiology , Evidence-Based Medicine , Humans , Hypercholesterolemia/blood , Hypercholesterolemia/complications , Intermittent Claudication/diagnostic imaging , Intermittent Claudication/etiology , Lipids/blood , Male , Middle Aged , Practice Guidelines as Topic , Radiography , Stents , Treatment Outcome
12.
Neurosurgery ; 63(6): 1185-90; discussion 1190-1, 2008 Dec.
Article in English | MEDLINE | ID: mdl-19057332

ABSTRACT

Thomas Willis is best known for the circle of Willis. The life story of this 17th- century medical genius, who remains an inspiration for all neuroscientists 300 years later, is summarized in this article. We outline his academic achievements, including his description of the famous basal arterial circle, and we attempt to obtain insight into his visionary thought process through this historical review.


Subject(s)
Circle of Willis , Neuroanatomy/history , Neurosciences/history , Physicians/history , History, 17th Century , Portraits as Topic
13.
Clin Neurol Neurosurg ; 110(5): 511-3, 2008 May.
Article in English | MEDLINE | ID: mdl-18329788

ABSTRACT

The authors report a rare case of an aneurysm arising at fenestrated anterior cerebral artery. The embryogenesis of this anatomical variation is discussed along with the review of relevant literature. Management of such lesions depends upon the location and morphology of the aneurysms and intracranial vascular anatomy. The authors discuss various management options and highlight possible technical difficulties that can be encountered in the surgical management of this rare sub-group of aneurysms.


Subject(s)
Aneurysm, Ruptured/surgery , Anterior Cerebral Artery/abnormalities , Intracranial Aneurysm/surgery , Intracranial Arteriovenous Malformations/surgery , Subarachnoid Hemorrhage/etiology , Aneurysm, Ruptured/complications , Aneurysm, Ruptured/pathology , Anterior Cerebral Artery/surgery , Humans , Intracranial Aneurysm/complications , Intracranial Aneurysm/pathology , Intracranial Arteriovenous Malformations/complications , Intracranial Arteriovenous Malformations/pathology , Male , Middle Aged , Rare Diseases/surgery , Subarachnoid Hemorrhage/pathology , Subarachnoid Hemorrhage/surgery , Treatment Outcome , Vascular Surgical Procedures/methods
14.
Clin Neurol Neurosurg ; 110(3): 276-8, 2008 Mar.
Article in English | MEDLINE | ID: mdl-18069124

ABSTRACT

We report two cases of broncho-pleural fistula resulting from trans-diaphragmatic migration of the distal catheter of a ventriculo-peritoneal shunt. Relevant literature on thoracic complications of a ventriculo-peritoneal shunt is reviewed. The clinical presentation, diagnosis and management of V-P shunt-related broncho-pleural fistulae are discussed.


Subject(s)
Bronchial Fistula/pathology , Foreign-Body Migration/pathology , Pleural Diseases/pathology , Ventriculoperitoneal Shunt/adverse effects , Accidents, Traffic , Adolescent , Adult , Bronchial Fistula/diagnostic imaging , Cough/complications , Female , Foreign-Body Migration/diagnostic imaging , Humans , Hydrocephalus/etiology , Male , Multiple Trauma/pathology , Pleural Diseases/diagnostic imaging , Pregnancy , Radiography, Thoracic
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