Quantitative Assessment of Ventriculostomy-Related Hemorrhage: A Volume-Based Classification System to Predict New Neurological Symptoms.

BACKGROUND: Hemorrhage is one of the most feared complications following ventriculostomy placement. Current studies have assessed factors associated with increased risk of ventriculostomy-related hemorrhage (VRH). However, the clinical significance of VRH has not been determined. OBJECTIVE: To correlate quantitative volumetric measurements of VRH with new neurological symptoms. METHODS: A retrospective review of our institutional database of ventriculostomy patients during the last decade was performed. Patients' demographics and procedural details such as indication, number of passes and position of the catheter were recorded. VRH volume was quantified on noncontrast head computed tomography using the Picture Archiving Communication System (Carestream Vue®, Rochester, New York) semi-automated livewire segmentation tool. Patients with new neurological symptoms within 48 h of VRH were considered symptomatic. Several clinical confounders were ruled out. Logistic regression analyses were performed. The best volumetric cut-offs in predicting symptomatic VRH were determined through receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 3090 patients underwent ventriculostomy procedures and 179 (∼6%) developed VRH. A total of 41 (1.06%) patients with VRH developed new neurological symptoms. Only 12 (0.39%) were attributable to a new VRH. Multivariable logistic regression showed that volume of the hemorrhage (OR 1.17, P = .006) is the only significant predictor of symptomatic VRH. ROC curve analysis demonstrated that VRH volume <1.10 cc has 91.7% sensitivity to rule out symptomatic VRH, whereas a volume >7.59 cc has 95.5% specificity to predict symptomatic VRH. CONCLUSION: Approximately 6% of patients developed postprocedural VRH, but only 0.4% were symptomatic. VRH volumes <1 cc are extremely unlikely to become symptomatic, whereas volumes >7.5 cc may predict development of new neurological deficits.

Transcirculation Approach for Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Study and Review of the Literature.

Background: Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, provide alternate endovascular routes when anterograde interventions are not feasible. We aimed to assess the safety and efficacy of mechanical thrombectomy (MT) through a transcirculation route. Methods: Six centers provided retrospective data on acute ischemic stroke (AIS) patients who underwent MT via transcirculation approaches. Demographics and technical details of the endovascular intervention were collected. Recanalization rates, peri-procedural complications and clinical/angiographic outcomes immediately after the procedure and at last available follow-up were assessed. A review of the literature reporting on AIS patients whom underwent transcirculation MT was also performed. Results: Our multicenter study included 14 AIS patients treated through transcirculation routes. Mean age was 57.8 ± 11.9 years, and 10 (71.4%) were men. Mean NIHSS at admission was 18.4 (range 8-27). TICI 2b-3 recanalization was achieved in 10/14 (71.4%) patients. Three patients died after intervention: one due to late recanalization, one due to acute in-stent thrombosis, and one due to a procedure-related thromboembolic brainstem infarct. Of 11 surviving patients with follow-up available (mean 9.7 months), mRS 0-2 was achieved in 6 (54.5%) cases. Our review of the literature pooled a total of 37 transcirculation MT cases. Most common occlusions were tandem lesions (ICA + MCA = 64.9%) and BA + bilateral VA (18.9%). ACOM and PCOM were crossed in 18 (48.6%) cases each; one patient required a combined ACOM-PCOM approach. Primary recanalization technique included intra-arterial (IA) thrombolytics alone in 10 (27%), angioplasty ± stenting in 6 (16.2%), stent-retriever in 8 (21.6%), contact aspiration in 6, and combined (MT ± IA-thrombolytics) in 6 cases. Twenty-eight (75.7%) AIS patients achieved successful TIMI 2-3/TICI 2b-3 recanalization. After a mean follow-up of 6.7 months, 23/31 (74.2%) patients achieved a favorable functional outcome. Conclusions: Transcirculation approaches may be used to access the target lesion when the parent artery cannot be crossed through conventional antegrade routes. These techniques are feasible but should be reserved as a bailout maneuver when anterograde MT is not possible. Newer endovascular devices have improved neurological and angiographic outcomes in transcirculation cases.

Transcirculation Approach for Endovascular Embolization of Intracranial Aneurysms, Arteriovenous Malformations, and Dural Fistulas: A Multicenter Study.

BACKGROUND: Unfavorable anatomy can preclude traditional anterograde endovascular interventions. Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, can provide alternative pathways for successful treatment of these patients. We aimed to assess the safety, efficacy, and outcomes of endovascular embolization through transcirculation approaches. METHODS: Nine centers provided retrospective data on patients who underwent transcirculation procedures for embolization of intracranial aneurysms (IAs), dural arteriovenous fistulas (dAVFs), and arteriovenous malformations (AVMs). Raymond-Roy Occlusion Classification (RROC) grades and degree of obliteration were used to evaluate treatment success. Minor/major complications and clinical/angiographic outcomes were also assessed. A review of the literature reporting patients who underwent transcirculation embolizations was also performed. RESULTS: Forty patients were included in the study (34 IAs, 3 AVMs, and 3 dAVFs). Most IAs (22/34, 64.7%) were treated electively. Three AVMs and 2 dAVFs presented ruptured. RROC grade I-II was achieved in 97% of IAs. All AVMs and dAVFs were completely obliterated. One patient developed a transient arterial thrombus that was successfully treated with intravenous tirofiban. The most common indications for a transcirculation approach were difficult access angle of the target lesion (42.5%) and occlusion of the parent artery (27.5%). The review of the literature pooled 152 IAs treated via transcirculation approaches. Most common locations were the basilar tip (27%), posterior inferior cerebellar artery (25%), and internal carotid artery (15.1%). The posterior communicating artery was crossed in 60 (39.5%), anterior communicating artery in 48 (31.6%), and vertebral artery in 37 (24.3%) patients. Primary coiling alone was performed in 22 (14.5%), stent-assisted coiling in 67 (44.1%), balloon-assisted coiling in 36 (23.7%), stent-assisted coiling + balloon-assisted coiling in 20 (13.2%) and flow diversion in 7 (4.6%) patients. After intervention, 142 (93.4%) IAs achieved successful RROC grades I-II. Two major complications (1.3%) leading to death were reported, both of which were intraprocedural aneurysmal ruptures with massive subarachnoid hemorrhage and herniation. After a mean angiographic follow-up of 11.3 months, only 6/108 (5.6%) IAs showed intrasaccular filling/recurrence. CONCLUSIONS: Transcirculation approaches seem to be safe and effective in the treatment of IAs, dAVFs, and AVMs. The most common indication for a transcirculation approach is the presence of a difficult angle to access the target lesion and occlusion of the parent artery.