Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial.

BACKGROUND AND PURPOSE: The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS: Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS: There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS: Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.

A simple relationship between radiological arteriovenous malformation hemodynamics and clinical presentation: a prospective, blinded analysis of 31 cases.

OBJECT: The authors sought to establish prospectively whether there is a simple relationship between radiological features of brain arteriovenous malformation (AVM) hemodynamics and a patient's clinical presentation. METHODS: Thirty-one consecutive patients with AVMs underwent cerebral angiography at 3.8 frames/second during each standardized injection of contrast material. Contrast dilution curves were derived from the image sequences by using regions of interest (ROIs) traced on arteries feeding and veins draining the AVM nidus. Angiographic parameters were then analyzed in a blinded fashion. These parameters included the times required to reach the peak contrast density, the contrast decay time, and fractions thereof, in the ROI for each vessel. The authors determined whether these parameters, the arteriovenous transit time, and/or AVM size were related to patients' presentation with hemorrhage (11 patients), seizure (11 patients), or other clinical symptoms (nine patients). Statistically significant results were found only in analyses of arterial phase times to reach peak contrast density. Analyses of venous parameters, AVM size, and nidus transit time showed trends but no statistical significance. Arterial filling with contrast material was significantly slower in patients presenting with hemorrhage (mean 50%, 80%, and 100% of time to peak +/- standard error [SE] = 1.19+/-0.13, 1.97+/-0.18, and 3.04+/-0.34 seconds, respectively) compared with patients presenting with seizures (mean 50%, 80%, and 100% of time to peak +/- SE = 0.80+/-0.12, 1.32+/-0.18, and 1.95+/-0.29 seconds, respectively) according to analysis of variance (p<0.05) and post-hoc t-tests (p<0.05) for each parameter. Patients who presented with other symptoms had intermediate arterial filling times. CONCLUSIONS: These simple hemodynamic parameters, which can be obtained without added risk to the patient, may help identify a subset of individuals in whom AVMs pose a higher risk of future hemorrhage and who may therefore warrant more expeditious treatment.

Endovascular management of paediatric intracranial aneurysms.

SUMMARY: The purpose of this paper is to discuss the radiological and clinical features of paediatric intracranial aneurysms including endovascular techniques currently being used for their therapy. Paediatric patients who presented with the diagnosis of intracranial aneurysm between August 1982 and February 1997 were included. The data were collected retrospectively. Clinical features included patient's age, sex, presentation, treatment and outcome. Radiologic features included location, size and number of aneurysms present. 21 patients (13 females and 8 males) ranging in age from 9 months to 16 years had intracranial aneurysms. Seventy six percent of the aneurysms were located in the anterior circulation and 24% in the posterior circulation. Seven patients (33%) had giant aneurysms and three patients (14%) had multiple aneurysms. Endovascular treatment was performed in six patients (29%) and neurosurgical treatment in eight patients (38%). Endovascular treatment included the use of coils and/or balloon occlusion. Of the remaining patients, two (9.5%) died prior to any surgical or radiological intervention. A further five patients (24%) were treated conservatively. Intracranial aneurysms in children demonstrate clinical and radiologic features that differ significantly from those seen in adults. There is a higher percentage of ICA termination aneurysms, giant aneurysms and posttraumatic aneurysms. However, aneurysms in children, like those in adults, can and have been successfully treated utilizing endovascular as well as neurosurgical techniques.

Pathological effects of angioplasty on vasospastic carotid arteries in a rabbit model.

To define the pathological effects of angioplasty on vasospastic arteries, 36 rabbits underwent angiography and induction of vasospasm by placement of blood-filled (vasospasm groups) or empty (control group) silastic sheaths around the cervical carotid arteries. Two (Day 2) or 7 days (Day 7) later, angiography was repeated and one carotid artery in each animal was dilated by balloon angioplasty. The rabbits were sacrificed 1 day, 7 days, or 3 to 4 weeks after angioplasty. Significant vasospasm developed after placement of silastic sheaths with blood (mean reductions in diameter 39% +/- 6% at Day 2 and 48% +/- 5% at Day 7). Arterial narrowing was less apparent in the control groups at Day 2 (24% +/- 7%). Angioplasty performed on Day 2 significantly increased arterial diameters of vasospastic arteries (50% +/- 7%; p < 0.05) but not those of control arteries (10% +/- 6%, p > 0.05). Angioplasty performed on Day 7 increased the arterial diameters by a similar degree (47% +/- 13%, not significant). Arteries remained dilated after angioplasty, although there was significant vasospasm 7 days after angioplasty when angioplasty was performed on Day 2. Blinded, semiquantitative histopathological study of the arteries showed that 3 to 4 weeks after angioplasty, there was significant endothelial proliferation and a trend for thinning of the tunica media. There were no significant changes in control arteries subjected to angioplasty. Angioplasty was not associated with significant arterial fibrosis as measured by hydroxyproline content (analysis of variance). The increase in endothelial proliferation and decrease in the thickness of the tunica media suggest that, in the rabbit model, angioplasty damages endothelial and smooth-muscle cells. This may be the basis for the observation that vasospastic arteries do not reconstrict after angioplasty.

Percutaneous transluminal angioplasty for cerebral vasospasm after subarachnoid hemorrhage.

OBJECTIVE: To assess the efficacy of percutaneous transluminal angioplasty. DESIGN: A retrospective case study covering the period January 1990 to December 1992. SETTING: A tertiary-care referral centre. PATIENTS: Thirteen patients, ranging in age from 23 to 57 years, who had suffered an aneurysmal subarachnoid hemorrhage and subsequent symptomatic vasospasm that had not responded to aggressive medical therapy. INTERVENTION: Percutaneous transluminal angioplasty of spastic cerebral arteries MAIN OUTCOME MEASURES: Neurologic improvement (improved level of consciousness or resolution of focal deficit) immediately after angioplasty and functional status at 6 months after angioplasty. RESULTS: Four (31%) patients showed neurologic improvement immediately after angioplasty. At 6 months, 5 (38%) of the 13 were independent, 2 (15%) were dependent (severely disabled), and 6 (46%) had died. Poor clinical grade at the time of angioplasty was associated with a poor outcome. CONCLUSIONS: Percutaneous transluminal angioplasty appears to be a safe procedure that is beneficial in some patients with symptomatic vasospasm refractory to aggressive hypervolemic, hypertensive therapy. The best results likely are obtained in patients of good clinical grade in whom new neurologic deficits have not become established, and angioplasty should not be delayed if medical therapy does not rapidly reverse the symptoms of vasospasm.

Amyloid destructive spondyloarthropathy causing cord compression: related to chronic renal failure and dialysis.

Destructive spondyloarthropathy is a recently recognized disease that has not been reported in the neurosurgical literature. It is associated with spinal amyloid deposition in long-term renal failure and dialysis, and it occurs increasingly as the number of dialysis patients and their survival times increase. Clinically, there is a multisegmental and often rapidly progressive radiculomyelopathy that may require emergency stabilization. The radiological features are disc space narrowing with erosion of vertebral end plates and subarticular cysts. The pathological features include deposition of amyloid, which stains with Congo Red and antibodies to beta-2-microglobulin. We present two cases with clinical, radiological, and pathological features and a review of the literature.