Cumulative radiation dose during hospitalization for aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Radiation exposure from neurointerventional procedures and diagnostic neuroimaging can be substantial, with many recommendations offered to guide the interventionalist in the conscientious use of ionizing radiation. Patients presenting with an aneurysmal subarachnoid hemorrhage can undergo multiple imaging procedures during a prolonged hospital course. Therefore, we reviewed a cohort of such patients to identify the sources and quantify the cumulative radiation exposure seen during their hospitalization. MATERIALS AND METHODS: We retrospectively reviewed a single-center experience with these patients to define the potential for short-term skin injury and long-term oncologic risk due to absorbed radiation dose and sources of ionizing radiation and their contribution to the cumulative absorbed dose to the cranial tissues. RESULTS: We demonstrated that substantial cumulative doses can be seen, with 87% of the cumulative absorbed dose occurring during neurointerventional procedures and 7% from CT. Mathematic modeling was performed identifying potential techniques to further reduce the cumulative radiation absorbed dose to these patients. CONCLUSIONS: We conclude that repetitive irradiation during the care of patients with aneurysmal subarachnoid hemorrhage can result in significant cumulative doses and a variety of techniques can be applied to reduce this absorbed dose. Use of radiation for diagnostic and therapeutic purposes during prolonged procedures of patients with subarachnoid hemorrhage demands diligence throughout the hospitalization.

Neuroform stent assisted aneurysm treatment: evolving treatment strategies, complications and results of long term follow-up.

INTRODUCTION: This report details experience with the Neuroform stent, with an emphasis on evolving treatment strategies, complication rates and treatment durability. METHODS: All patients undergoing Neuroform stent assisted aneurysm treatment were registered in prospectively maintained endovascular databases at two institutions. RESULTS: 284 patients with 302 aneurysms underwent aneurysm treatment with Neuroform during a 42-month study period. Imaging follow-up was available for 166 of 286 saccular aneurysms which were treated with stents and coils (average interval 12.9 months). 80 demonstrated progressive thrombosis (48.2%), 40 were unchanged (24.1%) and 46 (27.7%) demonstrated re-canalization, 25 (15.1%) of which were major recanalizations requiring retreatment. The vast majority of recanalizations and retreatments were observed in large or giant aneurysms. A cumulative total of 25 ischemic strokes (8.8%) and eight neurovascular deaths (2.8%) were recorded in these patients. Ten of these strokes were associated with transient deficits which went on to complete resolution by the time of discharge or at the initial clinical follow-up, yielding a significant stroke rate of 5.3%. Delayed (>48 h) complications, including four deaths-related to stroke (n=2, 6 days and 8 weeks post-procedure) and spontaneous parenchymal hemorrhages (n=2)-represent events which are a direct consequence of stenting and likely would not have been encountered in the context of standard non-stent supported embolization techniques. CONCLUSION: Neuroform facilitates the endovascular treatment of complex and wide necked cerebral aneurysms. However, complete occlusion at angiographic follow-up remains uncommon and is observed in only one-third of patients. Delayed complications (>48 h) represent an important component of the overall complications associated with Neuroform assisted aneurysm embolization.

Influence of patient age and stenosis location on wingspan in-stent restenosis.

BACKGROUND AND PURPOSE: Wingspan is a self-expanding, microcatheter-delivered microstent specifically designed for the treatment of symptomatic intracranial atherosclerotic disease. Our aim was to discuss the effect of patient age and lesion location on in-stent restenosis (ISR) rates after percutaneous transluminal angioplasty and stenting (PTAS) with the Wingspan system. MATERIALS AND METHODS: Clinical and angiographic follow-up results were recorded for all patients from 5 participating institutions. ISR was defined as >50% stenosis within or immediately adjacent (within 5 mm) to the implanted stent and >20% absolute luminal loss. For the present analysis, patients were stratified into younger (55 years) age groups. RESULTS: ISR occurred at a rate of 45.2% (14/31) in the younger group and 24.2% (15/62) in the older group (odds ratio, 2.6; 95% confidence interval, 1.03-6.5). In the younger group, ISR occurred after treatment of 13/26 (50%) anterior circulation lesions versus only 1/5 (20%) posterior circulation lesions. In the older group, ISR occurred in 9/29 (31.0%) anterior circulation lesions and 6/33 (18.2%) posterior circulation lesions. In young patients, internal carotid artery lesions (10/17 treated, 58.8%), especially those involving the supraclinoid segment (8/9, 88.9%), were very prone to ISR. When patients of all ages were considered, supraclinoid segment lesions had much higher rates of both ISR (66.6% versus 24.4%) and symptomatic ISR (40% versus 3.9%) in comparison with all other locations. CONCLUSION: Post-Wingspan ISR is more common in younger patients. This increased risk can be accounted for by a high prevalence of anterior circulation lesions in this population, specifically those affecting the supraclinoid segment, which are much more prone to ISR and symptomatic ISR than all other lesions.

Marginal sinus arteriovenous fistulas mimicking carotid cavernous fistulas: diagnostic and therapeutic considerations.

Marginal sinus fistulas (MSFs) are uncommon vascular anomalies. Occasionally, the dominant venous drainage is forced retrograde up the inferior petrosal sinus and into the cavernous sinus, causing chemosis, proptosis, and ocular hypertension, mimicking a carotid cavernous fistula. This atypical clinical presentation may lead to misdiagnosis and inappropriate hazardous treatment of an MSF. Identifying the site of the fistula and understanding the anatomy of the venous drainage are critical in providing appropriate, safe, and efficacious endovascular treatment.

Serum S-100beta as a possible marker of blood-brain barrier disruption.

Two brain-specific proteins, S-100beta and neuron-specific enolase (NSE), are released systemically after cerebral lesions, but S-100beta levels sometimes rise in the absence of neuronal damage. We hypothesized that S-100beta is a marker of blood-brain barrier (BBB) leakage rather than of neuronal damage. We measured both proteins in the plasma of patients undergoing iatrogenic BBB disruption with mannitol, followed by chemotherapy. Serum S-100beta increased significantly after mannitol infusion (P<0.05) while NSE did not. This suggests that S-100beta is an early marker of BBB opening that is not necessarily related to neuronal damage.