Flow Preserving Endovascular Treatment of Traumatic Pseudoaneurysms of the Distal Anterior Cerebral Artery-Case Reports and Review of Literature.

Traumatic intracranial pseudoaneurysms (tIPAs) are a very rare pathology caused by blunt or penetrating head trauma. Diagnostic and therapeutic challenges of tIPAs are due to their unpredictable onset during the initial injury, or in a delayed manner, their unclear traumatic mechanism. Moreover, the presence of subarachnoid, subdural, or intraventricular hematoma may often cause them to be overlooked, which can potentially be followed by lethal rebleeding. Treatment of these lesions is controversial and on a case-by-case basis with regard to endovascular therapy or open surgery. We report two cases of three tIPAs of the distal anterior cerebral artery (dACA) with immediate and delayed onset after the trauma. Endovascular therapy resulted in complete obliteration of lesions with flow preservation in the parent artery using the flow diverter-assisted coiling strategy. The aim of this manuscript is to discuss the mechanism, angioanatomical characteristics, and current treatment options for these exceptional lesions.

Acute Management Should Be Optimized in Patients with Less Specific Stroke Symptoms: Findings from a Retrospective Observational Study.

Anterior circulation stroke (ACS) is associated with typical symptoms, while posterior circulation stroke (PCS) may cause a wide spectrum of less specific symptoms. We aim to assess the correlation between the initial presentation of acute ischemic stroke (AIS) symptoms and the treatment timeline. Using a retrospective, observational, single-center study, the set consists of 809 AIS patients treated with intravenous thrombolysis (IVT) and/or endovascular treatment (EVT). We investigate the impact of baseline clinical AIS symptoms and the affected vascular territory on recanalization times in patients treated with IVT only and EVT (±IVT). Regarding the IVT-only group, increasing the National Institutes of Health Stroke Scale (NIHSS) score on admission and speech difficulties are associated with shorter (by 1.59 ± 0.76 min per every one-point increase; p = 0.036, and by 24.56 ± 8.42 min; p = 0.004, respectively) and nausea/vomiting with longer (by 43.72 ± 13.13 min; p = 0.001) onset-to-needle times, and vertigo with longer (by 8.58 ± 3.84 min; p = 0.026) door-to-needle times (DNT). Regarding the EVT (±IVT) group, coma is associated with longer (by 22.68 ± 6.05 min; p = 0.0002) DNT, anterior circulation stroke with shorter (by 47.32 ± 16.89 min; p = 0.005) onset-to-groin time, and drooping of the mouth corner with shorter (by 20.79 ± 6.02 min; p = 0.0006) door-to-groin time. Our results demonstrate that treatment is initiated later in strokes with less specific symptoms than in strokes with typical symptoms.

Mechanical thrombectomy performed in thrombosed fusiform aneurysm after surgery for craniopharyngioma in adult.

INTRODUCTION: Fusiform dilatation of the internal carotid artery (ICA) is reported as a possible complication of craniopharyngioma resection in childhood. Here, the authors describe such a complication in an adult patient who presented with acute symptomatic thrombosis 7 months after surgery. MATERIALS AND METHODS: A 45-year-old woman presented with left hemispheric stroke due to a thrombotic supraclinoid occlusion of the terminal ICA (so called "T" occlusion). Successful revascularisation was achieved with mechanical thrombectomy. Beside recanalization of the M1 middle cerebral artery segment and ICA, an irregular filling of the fusiform aneurysm of the communicating segment of the left ICA was observed. The patient recovered after mechanical thrombectomy with no clinical sequelae. Due to the persistent filling of the aneurysm sac, a flow diverter stent was deployed across the diseased vessel segment two weeks later. The patient underwent resection of the craniopharyngioma from ipsilateral pterional craniotomy 7 months ago. Five years later the patient works full time as a nurse with no regrowth of the craniopharyngioma and no aneurysm reperfusion. RESULTS: This case, together with four other previously reported cases, documents that fusiform aneurysm as a complication of the craniopharygioma resection is not restricted to the childhood population but may also rarely occur in adults. As the patient suffered from acute symptomatic thrombosis which required treatment under the protocol for acute large vessel occlusions, we decided to treat the aneurysm with the flow diverter stent.

Outcomes of Urgent Carotid Endarterectomy for Crescendo Transient Ischemic Attacks and Stroke in Evolution.

BACKGROUND: Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (≤48 hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE). METHODS: A retrospective analysis was performed using prospectively collected data from all consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI), surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale (NIHSS) score variation, and functional outcome at 90 days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE). RESULTS: A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85 ± 5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31 ± 6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3 months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS ≤ 2). CONCLUSIONS: Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes.

Mechanical Thrombectomy for Acute Ischemic Stroke in Czech Republic: Technical Results from the Year 2016.

BACKGROUND AND PURPOSE: Experienced multidisciplinary stroke team and well-organized hospital management are considered necessary to achieve good results after mechanical thrombectomy (MT) in acute ischemic stroke patients. We analyzed the technical results of MT performed in the Czech Republic in the year 2016 to provide relevant data for further quality improvement. MATERIAL AND METHODS: All centers performing MT in the CR were called for detailed technical and clinical data from year 2016, which were anonymously analyzed and relevant technical key time intervals were compared. Clinical outcomes were assessed according to the HERMES meta-analysis. RESULTS: In the 2016, 1053 MTs were performed in the CR. Of 15 dedicated centers, the data from 12 centers and from 886 (84%) patients (49.2% males, mean age 69.8 ± 12.3 years) were analyzed. The overall median of time from hospital arrival to groin puncture (GP) was 77 min with a range from 40 to 109 min among individual hospitals, from GP to first passage of stent retriever 20 (15-40) min and from GP to maximal reached recanalization 42 (33-80) min. The median of recanalization time was 240 (219-320) min. The recanalization (TICI 2b-3) was achieved in 81.7% of patients, 44.1% of patients had a good 3-month clinical outcome and 6.3% suffered from symptomatic intracerebral hemorrhage. Peri-procedural complications were recorded in 89 (10%) patients. CONCLUSION: Despite achieved good overall results, a great variability in some of the analyzed key time intervals among individual centers performing MT warrants further quality improvement.

Endovascular Treatment of Symptomatic Thoracic Aneurysm Due to Periaortic Lymphoma.

An aggressive periaortic lymphoma could very rarely invade the aortic wall. We present a unique case of a patient with symptomatic thoracic aneurysm and imminent rupture due to the periaortic lymphoma, in which endovascular treatment using stent graft was applied. After stabilization of the aorta and histological confirmation of aggressive B-cell lymphoma by computed tomography-guided biopsy, the antilymphoma therapy was initiated. Despite the full treatment, the patient died 12 months later.

Fibrin Clot Architecture in Acute Ischemic Stroke Treated With Mechanical Thrombectomy With Stent-Retrievers　- Cohort Study.

BACKGROUND: The composition of intra-arterial clots might influence the efficacy of mechanical thrombectomy (MT) in ischemic stroke (IS) due to the acute occlusions within large cerebral arteries. The aims were to assess the factors associated with blood clot structure and the impact of thromboembolus structure on MT using stent-retrievers in patients with acute large artery IS in the anterior circulation.Methods and Results:In an observational cohort study, we studied the components of intra-arterial clots retrieved from large cerebral arteries in 80 patients with acute IS treated with MT with or without i.v. thrombolysis (IVT). Histology of the clots was carried out without knowledge of the clinical findings, including the treatment methods. The components of the clots, their age, origin and semi-quantitative graded changes in the architecture of the fibrin components (e.g., "thinning") were compared via neuro-interventional, clinical and laboratory data. The most prominent changes in the architecture of the fibrin components in the thromboemboli were associated with IVT (applied in 44 patients; OR, 3.50; 95% CI: 1.21-10.10, P=0.02) and platelet count (OR, 2.94; 95% CI: 1.06-8.12, P=0.04). CONCLUSIONS: In patients with large artery IS treated with the MT using stent-retrievers, bridging therapy with IVT preceding MT and higher platelet count were associated with significant changes of the histological structure of blood clots.

Mechanical recanalization in ischemic anterior circulation stroke within an 8-hour time window: a real-world experience.

PURPOSE: We aimed to assess the safety and effectiveness of mechanical recanalization in patients with ischemic stroke in the anterior circulation within 8 h since symptoms onset and with unknown onset time. We compared time intervals <6 h vs. 6-8 h/unknown onset time, as only limited data are available for a time window beyond 6 h. METHODS: Our cohort included 110 consecutive patients (44 males; mean age, 73.0±11.5 years) with ischemic stroke in the anterior circulation due to the acute occlusion of a large intracranial artery who underwent mechanical recanalization within an 8-hour time window or with unknown onset time. All patients underwent unenhanced computed tomography (CT) of the brain, CT angiography of the cervical and intracranial arteries and digital subtraction angiography. Perfusion CT was performed in patients beyond a 6-hour time window/with unknown onset time. We collected the following data: baseline characteristics, presence of risk factors, neurologic deficit at the time of treatment, time to therapy, recanalization rate, and 3-month clinical outcome. Successful recanalization was defined as Thrombolysis in Cerebral Infarction score of 2b/3 and good clinical outcome as modified Rankin scale value of 0-2 points. RESULTS: Successful recanalization was achieved in 82 patients (74.5%): in 61 patients treated within 6 h (73.5%), 7 patients treated within 6-8 h (63.6%), and 13 patients with unknown onset time (81.3%). Good 3-month clinical outcome was achieved in 61 patients (55.5%): in 46 patients treated within 6 h (55.4%), 5 patients treated within 6-8 h (45.5%), and 10 patients with unknown onset time (62.5%). Recanalization success or clinical outcome were not significantly different between patients treated at different time windows. CONCLUSION: Our data confirms the safety and effectiveness of mechanical recanalization performed in carefully selected patients with ischemic stroke in the anterior circulation within 8 h of stroke onset or with unknown onset time in everyday practice.

Safety of Early Carotid Endarterectomy after Intravenous Thrombolysis in Acute Ischemic Stroke.

BACKGROUND: The timing of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) is still a controversial issue. The aim of this study was to assess the safety of early carotid interventions in patients treated with thrombolysis for acute ischemic stroke. METHODS: A retrospective analysis was performed using prospectively collected data from consecutive patients who underwent CEA for symptomatic internal carotid artery stenosis within 14 days after the index neurological event during the period from January 2013 to July 2016. Patients who had undergone IVT before CEA were identified. The primary outcome measures were any stroke and death rate at 30 days, symptomatic intracerebral hemorrhage and surgical site bleeding requiring intervention. RESULTS: A total of 93 patients were included for the final analysis. Among these, 13 (14.0%) patients had undergone IVT before CEA while 80 (86.0%) patients had CEA only. The median time interval between IVT and CEA was 2 days (range: 0-13). A subgroup of 6 patients underwent CEA within 24 hours of administration of IVT. The 30-day combined stroke and death rate was 7.7% (1 of 13) among patients undergoing IVT before CEA and 5.0% (4 of 80) among those undergoing CEA only (P = 0.690). In the IVT group, there were no cerebral hemorrhages or significant surgical site bleeding events requiring reintervention. CONCLUSIONS: Our experience indicates that CEA performed early after IVT for acute ischemic stroke, aiming not only to reduce the risk of stroke recurrence but also to achieve neurological improvement by reperfusion of the ischemic penumbra, may be safe and can lead to favorable outcomes.

Emergent Carotid Thromboendarterectomy for Acute Symptomatic Occlusion of the Extracranial Internal Carotid Artery.

BACKGROUND: Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with an extremely poor prognosis. The best treatment approach in this setting is still unknown. The aim of our study was to evaluate the efficacy, safety, and outcomes of emergent surgical revascularization of acute extracranial ICA occlusion in patients with minor to severe ischemic stroke. METHODS: A retrospective analysis was performed using prospectively collected data of consecutive patients who underwent carotid thromboendarterectomy for symptomatic acute ICA occlusion during the period from January 2013 to December 2015. Primary outcomes were disability at 90 days assessed by the modified Rankin Scale (mRS) and neurological deficit at discharge assessed using the National Institute of Health Stroke Scale (NIHSS). Secondary outcomes were the recanalization rate, 30-day overall mortality, and any intracerebral bleeding. RESULTS: During the study period, a total of 6 patients (5 men and 1 woman) with a median age of 64 years (range: 58-84 years) underwent emergent reconstruction for acute symptomatic ICA occlusion within a median of 5.4 hours (range: 2.9-12.0 hours) after symptoms onset. The median presenting NIHSS score was 10.5 points (range: 4-21). Before surgery, 4 patients (66.7%) had been treated by systemic recombinant tissue plasminogen activator lysis. The median time interval between initiation of intravenous thrombolysis and carotid thromboendarterectomy was 117.5 minutes (range: 65-140 minutes). Patency of the ICA was achieved in all patients. On discharge, the median NIHSS score was 2 points (range: 0-11 points). There was no postoperative intracerebral hemorrhage and zero 30-day mortality rate. At 3 months, 5 patients (83.3%) had a good clinical outcome (mRS ≤ 2). CONCLUSION: Patients presenting with minor to severe ischemic stroke syndromes due to isolated extracranial ICA occlusion may benefit from emergent carotid revascularization. Thorough preoperative neuroimaging is essential to aid in selecting eligible candidates for acute surgical intervention.

Integration of endovascular therapy of ruptured abdominal and iliac aneurysms in the treatment algorithm: a single-center experience in a medium-volume vascular center.

PURPOSE: To evaluate the influence of endovascular therapy of ruptured abdominal or iliac aneurysms on total mortality. MATERIALS AND METHODS: We analyzed the mortality of 40 patients from 2005 to 2009, when only surgical treatment was available. These results were compared with the period 2010 to 2013, when endovascular aneurysm repair (EVAR) was assessed as the first option in selected patients. RESULTS: During 2005 to 2009, the mortality was 37.5%. From 2010 to 2013, 45 patients were treated with mortality 28.9%. Open repair was performed in 35 (77.8%) patients and EVAR in 10 (22.2%) patients. The 30-day and 1-year mortality rates of the EVAR group were 0% and 20%, respectively, and the total mortality rate was 30% during follow-up (median 11 months, range 1-42 months). The 30-day mortality in the surgical group remained unchanged, at 37.1%, and 1-year and total mortality rates were 45.7% and 51.4%, respectively. CONCLUSION: Following integration in the treatment algorithm, EVAR decreased total mortality in our center by 8.6%.

Periprocedural risk and long-term outcome of intracranial angioplasty based on a single-centre experience.

BACKGROUND: Intracranial atherosclerotic stenosis is a major cause of stroke and yet there are currently no proven effective treatments for it. The SAMMPRIS trial, comparing aggressive medical management alone with aggressive medical management combined with intracranial angioplasty and stenting, was prematurely halted when an unexpectedly high rate of periprocedural events was found in the endovascular arm. The goal of our study is to report the immediate and long-term outcomes of patients with ≥ 70 % symptomatic intracranial atherosclerotic stenosis treated with balloon angioplasty and stent placement in a single centre. PATIENTS AND METHODS: This is a retrospective review of 37 consecutive patients with 42 procedures of ballon angioplasty and stenting for intracranial atherosclerotic stenosis (≥ 70 % stenosis) treated between 1999 and 2012. Technical success (residual stenosis ≤ 50 %), periprocedural success (no vascular complications within 72 hours), and long-term outcomes are reported. RESULTS: Technical and periprocedural success was achieved in 90.5 % of patients. The within 72 hours periprocedural stroke/death rate was 7.1 % (4.8 % intracranial haemorrhage), and the 30-day stroke/death rate was 9.5 %. Thirty patients (81 %) had clinical follow-up at ≥ 6 months. During follow-up, 5 patients developed 6 ischemic events; 5 of them (17 %) were ipsilateral. The restenosis rate was 27 %, and the retreatment rate was 12 %. CONCLUSIONS: Our outcomes of the balloon angioplasty/stent placement for intracranial atherosclerotic stenosis are better than those in the SAMMPRIS study and compare favourably with those in large registries and observational studies.

Coronary subclavian steal syndrome causing acute myocardial infarction in a patient undergoing coronary-artery bypass grafting.

Coronary subclavian steal syndrome with retrograde blood flow in the left internal mammary-coronary bypass graft is a rare but severe complication of cardiac surgery. The authors present a case of a 68-year-old man after coronary-artery bypass grafting using an internal mammary artery. He had been suffering from angina pectoris for the last several years before surgery. The patient was resuscitated at home by emergency medical service because of primary ventricular fibrillation due to an acute myocardial infarction 5 years after surgery. An occlusion of the left subclavian artery with the retrograde blood flow in the left internal mammary coronary bypass was found. This could have been the cause of insufficiency in coronary blood flow and ischemia of the myocardial muscle. The subclavian artery occlusion was successfully treated with percutaneous transluminal angioplasty and implantation of 2 stents. The patient remained free of any symptoms 2 years after this procedure.

Influence of the secondary deployment of expanded polytetrafluoroethylene-covered stent grafts on maintenance of transjugular intrahepatic portosystemic shunt patency.

PURPOSE: To evaluate the effects of secondary deployment of expanded polytetrafluoroethylene (ePTFE)-covered stent grafts in the treatment of dysfunctional transjugular intrahepatic portosystemic shunts (TIPSs) in comparison with other common approaches (conventional angioplasty or implantation of bare metal stents). MATERIALS AND METHODS: A retrospective review of 121 dysfunctional bare metal TIPS presenting between 2000 and 2004 was conducted. The group was divided into four subgroups according to the type of intervention: conventional angioplasty (52 cases; 43%), bare metal stent deployment (35 cases; 28.9%), nondedicated ePTFE-covered stent-graft deployment (15 cases; 12.4%), and dedicated ePTFE-covered stent-graft deployment (19 cases; 15.7%). In all four groups, the primary patency after the specific intervention was calculated and mutually compared. RESULTS: Primary patency rates after 12 and 24 months were 49.7% and 25.3%, respectively, in conventional angioplasty; 74.9% and 64.9%, respectively, with bare metal stents; 75.2% and 64.5%, respectively, with nondedicated ePTFE-covered stent grafts; and 88.1% and 80.8%, respectively, with dedicated ePTFE-covered stent grafts. CONCLUSIONS: In the treatment of dysfunctional TIPS, better patency after the intervention was obtained by deploying dedicated ePTFE-covered stent grafts in comparison with conventional angioplasty, bare metal stents, and nondedicated ePTFE-covered stents.

Contrast-enhanced MR angiography utilizing parallel acquisition techniques in renal artery stenosis detection.

Significant renal artery stenosis (RAS) is a potentially curable cause of renovascular hypertension and/or renal impairment. It is caused by either atherosclerosis or fibromuscular dysplasia. Correct and timely diagnosis remains a diagnostic challenge. MR angiography (MRA) as a minimally invasive method seems to be suitable for RAS detection, however, its diagnostic value widely differs in the literature (sensitivity 62-100% and specificity 75-100%). The aim of our prospective study was to compare the diagnostic value of contrast-enhanced MRA utilizing parallel acquisition techniques in the detection of significant RAS with digital subtraction angiography (DSA). A total of 78 hypertensive subjects with suspected renal artery stenosis were examined on a 1.5 Tesla MR system using a body array coil. Bolus tracking was used to monitor the arrival of contrast agent to the abdominal aorta. The MRA sequence parameters were as follows: TR 3.7 ms; TE 1.2 ms; flip angle 25 degrees; acquisition time 18s; voxel size 1.1 mm x1.0 mm x 1.1 mm; centric k-space sampling; parallel acquisition technique with acceleration factor of 2 (GRAPPA). Renal artery stenosis of 60% and more was considered hemodynamically significant. The results of MRA were compared to digital subtraction angiography serving as a standard of reference. Sensitivity and specificity of MRA in the detection of hemodynamically significant renal artery stenosis were 90% and 96%, respectively. Prevalence of RAS was 39% in our study population. Contrast-enhanced MRA with high spatial resolution offers sufficient sensitivity and specificity for screening of RAS.

Liver metastases from uveal melanoma: clinical experience of hepatic arterial infusion of cisplatin, vinblastine and dacarbazine.

BACKGROUND/AIMS: Liver is the most common site of metastases in uveal melanoma. Hepatic arterial infusion of cytotoxic agents may be an effective method of controlling the disease in these patients. METHODOLOGY: A retrospective analysis of 10 patients with hepatic metastases of uveal melanoma treated with hepatic arterial infusion (HAI) of the combination of cisplatin, vinblastine and dacarbazine was performed. RESULTS: Two patients had an objective response, 4 patients had stable disease and 4 patients had progressive disease. The median survival from the start of therapy was 16 (range 5 - 69) months. HAI of second line agents was of limited effectiveness. All patients with progressive disease died within one year while all patients with clinical benefit response (objective response or stable disease) survived more than one year. CONCLUSIONS: Present data demonstrate, in agreement with the literature, the effectiveness of HAI in the treatment of uveal melanoma metastatic to the liver. The HAI of combination of cisplatin, vinblastine and dacarbazine seems to have similar efficacy as other HAI regimens.

Transcatheter closure of a chronic iatrogenic arteriovenous fistula between the carotid artery and the brachiocephalic vein with an Amplatzer duct occluder in combination with a carotid stent.

We report an original method of transcatheter closure of an arteriovenous fistula using the combination of an Amplatzer PDA occluder and a carotid stent. The fistula was between the left carotid artery and the brachiocephalic vein. The patient had significant left-to-right shunt and was highly symptomatic. Due to the large orifice and pseudoaneurysmatic enlargement of the fistula, we had to use a large Amplatzer PDA occluder and the protruding part of the PDA device disk had to be covered with a carotid stent. The fistula was completely closed. The patient stopped having symptoms and, 2 years after the procedure, the effect persists.

Endovascular treatment of acute and chronic thoracic aortic injury.

Our aim is to present midterm results after endovascular repair of acute and chronic blunt aortic injury. Between December 1999 and December 2005, 13 patients were endovascularly treated for blunt aortic injury. Ten patients, 8 men and 2 women, mean age 38.7 years, were treated for acute traumatic injury in the isthmus region of thoracic aorta. Stent-graftings were performed between the fifth hour and the sixth day after injury. Three patients (all males; mean age, 66 years; range, 59-71 years) were treated due to the presence of symptoms of chronic posttraumatic pseudoaneurysm of the thoracic aorta (mean time after injury, 29.4 years, range, 28-32). Fifteen stent-grafts were implanted in 13 patients. In the group with acute aortic injury one patient died due to failure of endovascular technique. Lower leg paraparesis appeared in one patient; the other eight patients were regularly followed up (1-72 months; mean, 35.6 months), without complications. In the group with posttraumatic pseudoaneurysms all three patients are alive. One patient suffered postoperatively from upper arm claudication, which was treated by carotidosubclavian bypass. We conclude that the endoluminal technique can be used successfully in the acute repair of aortic trauma and its consequences. Midterm results are satisfactory, with a low incidence of neurologic complications.