A Multicenter Pilot Study on the Clinical Utility of Computational Modeling for Flow-Diverter Treatment Planning.

BACKGROUND AND PURPOSE: Selection of the correct flow-diverter size is critical for cerebral aneurysm treatment success, but it remains challenging due to the interplay of device size, anatomy, and deployment. Current convention does not address these challenges well. The goals of this pilot study were to determine whether computational modeling improves flow-diverter sizing over current convention and to validate simulated deployments. MATERIALS AND METHODS: Seven experienced neurosurgeons and interventional neuroradiologists used computational modeling to prospectively plan 19 clinical interventions. In each patient case, physicians simulated 2-4 flow-diverter sizes that were under consideration based on preprocedural imaging. In addition, physicians identified a preferred device size using the current convention. A questionnaire on the impact of computational modeling on the procedure was completed immediately after treatment. Rotational angiography image data were acquired after treatment and compared with flow-diverter simulations to validate the output of the software platform. RESULTS: According to questionnaire responses, physicians found the simulations useful for treatment planning, and they increased their confidence in device selection in 94.7% of cases. After viewing the simulations results, physicians selected a device size that was different from the original conventionally planned device size in 63.2% of cases. The average absolute difference between clinical and simulated flow-diverter lengths was 2.1 mm. In 57% of cases, average simulated flow-diverter diameters were within the measurement uncertainty of clinical flow-diverter diameters. CONCLUSIONS: Physicians found computational modeling to be an impactful and useful tool for flow-diverter treatment planning. Validation results showed good agreement between simulated and clinical flow-diverter diameters and lengths.

A Patient Dose-Reduction Technique for Neuroendovascular Image-Guided Interventions: Image-Quality Comparison Study.

BACKGROUND AND PURPOSE: The ROI-dose-reduced intervention technique represents an extension of ROI fluoroscopy combining x-ray entrance skin dose reduction with spatially different recursive temporal filtering to reduce excessive image noise in the dose-reduced periphery in real-time. The aim of our study was to compare the image quality of simulated neurointerventions with regular and reduced radiation doses using a standard flat panel detector system. MATERIALS AND METHODS: Ten 3D-printed intracranial aneurysm models were generated on the basis of a single patient vasculature derived from intracranial DSA and CTA. The incident dose to each model was reduced using a 0.7-mm-thick copper attenuator with a circular ROI hole (10-mm diameter) in the middle mounted inside the Infinix C-arm. Each model was treated twice with a primary coiling intervention using ROI-dose-reduced intervention and regular-dose intervention protocols. Eighty images acquired at various intervention stages were shown twice to 2 neurointerventionalists who independently scored imaging qualities (visibility of aneurysm-parent vessel morphology, associated vessels, and/or devices used). Dose-reduction measurements were performed using an ionization chamber. RESULTS: A total integral dose reduction of 62% per frame was achieved. The mean scores for regular-dose intervention and ROI dose-reduced intervention images did not differ significantly, suggesting similar image quality. Overall intrarater agreement for all scored criteria was substantial (Kendall τ = 0.62887; P < .001). Overall interrater agreement for all criteria was fair (κ = 0.2816; 95% CI, 0.2060-0.3571). CONCLUSIONS: Substantial dose reduction (62%) with a live peripheral image was achieved without compromising feature visibility during neuroendovascular interventions.

Endovascular intracranial treatment of acute ischemic strokes.

Acute ischemic stroke (AIS) is the leading cause of long-term disability and the second cause of death worldwide. Intravenous (IV) tissue plasminogen activator (tPA) remains the only FDA-approved treatment for AIS. The use of IV tPA in AIS related to large-vessel occlusion (LVO) has shown low recanalization rates and poor clinical outcomes. Over the last decade, endovascular treatment has demonstrated safety and effectiveness in the management of LVO-associated AIS due to the evolution of endovascular techniques and technologies, beginning with intraarterial thrombolysis, aspiration, self- expanding intracranial stents, and now retrievable stents. With the recent publication of the results of 5 randomized controlled studies, mechanical thrombectomy in combination with IV tPA demonstrated significant radiographic and clinical benefit over traditional strategies with IV tPA alone. In light of these results, endovascular therapy has been placed at the forefront of stroke treatment, redefining the standard of care. This review presents the evolution of endovascular treatment of AIS resulting from LVO; provides an analysis of the initial and latest RCTs; and discusses the association between endovascular mechanical thrombectomy and clinical outcomes, functional outcomes, and rates of revascularization, intracranial hemorrhage, morbidity, and mortality. Finally, shortcomings of the recent technological advances, such as clot fragmentation, and potential solutions to overcome these drawbacks are presented.

Bilateral paramedian thalamic and mesencephalic infarcts after basilar tip aneurysm coiling: role of the artery of Percheron.

Aneurysm embolization using Guglielmi detachable coils (GDC) is gaining acceptance as a viable alternative for surgery in the treatment of aneurysms. Recent reports describe a significant rate of thromboembolic complications. Thalamic and midbrain blood supply can arise from complex anatomical variations. The rare variation: "artery of Percheron", is a solitary arterial trunk arising from one of the proximal segments of a posterior cerebral artery and supplies the paramedian thalami and rostral midbrain bilaterally. We describe a patient that underwent elective endovascular treatment for a basilar tip aneurysm using GDC and stents in each PCA; 12 hours later patient was comatose and not following commands. Sequential magnetic resonance imaging (MRI) of brain showed bilateral paramedian thalamic and mesencephalic infarcts presumably secondary to artery of Percheron occlusion. Thromboembolic event related to the use of the GDC embolization and stents is a rare clinical sequelae, but catastrophic. The use of antiplatelets agents should be reinforced in the scenario. When bilateral medial thalamic and midbrain infarcts are found, occlusion of the artery of Percheron should be considered. Angiography may not b helpful and lack of visualization of the artery does not exclude its presence. In this case the MRI findings confirmed the presence of the infarction based on the anatomical distribution.

Bilateral paramedian thalamic and mesencephalic infarcts after basilar tipaneurysm coiling: role of the artery of Percheron

Aneurysm embolization using Guglielmi detachable coils (GDC) is gaining acceptance as a viable alternative for surgery in the treatment of aneurysms. Recentreports describe a significant rate of thromboembolic complications. Thalamic and midbrain blood supplycan arise from complex anatomical variations. The rarevariation: "artery of Percheron", is a solitary arterialtrunk arising from one of the proximal segments of aposterior cerebral artery and supplies the paramedianthalami and rostral midbrain bilaterally. We describe apatient that underwent elective endovascular treatment for a basilar tip aneurysm using GDC and stents ineach PCA; 12 hours later patient was comatose and notfollowing commands. Sequential magnetic resonance imaging (MRI) of brain showed bilateral paramedian thalamic and mesencephalic infarcts presumably secondaryto artery of Percheron occlusion. Thromboembolic event related to the use of the GDC embolization and stents is a rare clinical sequelae, but catastrophic. Theuse of antiplatelets agents should be reinforced in the scenario. When bilateral medial thalamic and midbraininfarcts are found, occlusion of the artery of Percheron should be considered. Angiography may not b help fuland lack of visualization of the artery does not excludeits presence. In this case the MRI findings confirmedthe presence of the infarction based on the anatomical distribution (AU)

La técnica endovascular para el manejo de aneurismas está ganando auge como una alternativa a la cirugía abierta. Sin embargo, se han descrito diferentes complicaciones tromboembólicas relacionadas con esta modalidad. El flujo sanguíneo al tálamo y almesencéfalo puede surgir de variaciones anatómicas complejas. La variación infrecuente: "arteria de Percheron", es una rama arterial solitaria que se originadel segmento proximal de una de la arterias cerebralesposteriores.Presentamos un paciente que tuvo un procedimiento endovascular electivo para el tratamiento de un aneurisma de la punta de la arteria basilar; 12 horas después del procedimiento, el paciente estaba clínicamente encoma profundo. La resonancia magnética (RM) cerebral mostró infartos talámicos paramediales bilaterales y mesencefálicos, compatible con la oclusión de la arteriade Percheron.Los eventos tromboembólicos relacionados con eluso de embolización con coil y stents es una rara pero catastrófica secuela. El uso de agentes antiplaquetarios se debe de recomendar en este tipo de situaciones. Cuando existen infartos talámicos paramediales bilaterales y mesencefálicos, la oclusión de la arteria de Percheron sedebe de tener en mente. La angiografía puede no ser demucha utilidad y la falta de visualización de la arteria no excluye su presencia. En este caso los hallazgos en la RM cerebral confirman la presencia de un infarto basado en la distribución anatómica de la arteria de Percheron (AU)

Hemorrhagic stroke with intraventricular extension in the setting of acute posterior reversible encephalopathy syndrome (PRES): case report.

We report the case of an eighteen year-old pregnant female with preeclampsia and florid signs and symptoms of posterior reversible encephalopathy syndrome (PRES) in whom intracerebral hemorrhage was evidenced following delivery. Management included blood pressure control, external ventricular drainage and lumboperitoneal shunt. To our knowledge this is the first report of intracranial hemorrhage occurring concurrently with peripartum acute PRES. This case was successfully treated with good outcome upon conclusion of management, thus making awareness of this potentially fatal complication and its suggested management for successful outcome necessary for neurosurgeons, neurologists and intensivists alike.

Endoscopic management of brainstem injury due to ventriculoperitoneal shunt placement.

INTRODUCTION: We report a patient who suffered from brainstem injury following ventriculoperitoneal (VP) shunt placement in the fourth ventricle. DISCUSSION: A 20-year-old man with complex hydrocephalus and trapped fourth ventricle underwent a suboccipital placement of a VP shunt. Postprocedure patient developed double vision. Magnetic resonance imaging showed that the catheter was penetrating the dorsal brainstem at the level of the pontomedullary junction. Patient was referred to our Neuroendoscopic Clinic. Physical exam demonstrated pure right VI cranial nerve palsy. Patient underwent flexible endoscopic exploration of the ventricular system. Some of the endoscopic findings were severe aqueductal stenosis and brainstem injury from the catheter. Aqueductoplasty, transaqueductal approach into the fourth ventricle, and endoscopic repositioning of the catheter were some of the procedures performed. Patient recovered full neurological function. The combination of endoscopic exploration and shunt is a good alternative for patients with complex hydrocephalus. A transaqueductal approach to the fourth ventricle with flexible scope is an alternative for fourth ventricle pathology.

Hemorrhagic stroke with intraventricular extension in the setting of acute posteriorreversible encephalopathy syndrome (PRES): case report

We report the case of an eighteen year-old pregnantfemale with preeclampsia and florid signs andsymptoms of posterior reversible encephalopathy syndrome(PRES) in whom intracerebral hemorrhage wasevidenced following delivery. Management includedblood pressure control, external ventricular drainageand lumboperitoneal shunt. To our knowledge this isthe first report of intracranial hemorrhage occurringconcurrently with peripartum acute PRES. This casewas successfully treated with good outcome upon conclusionof management, thus making awareness of thispotentially fatal complication and its suggested managementfor successful outcome necessary for neurosurgeons,neurologists and intensivists alike (AU)

Describimos el caso de una mujer embarazada de18 años con preeclampsia y signos y síntomas floridosde leucoencefalopatía posterior reversible (LPR) en laque se evidenció la presencia de hemorragia cerebraltras el parto. El tratamiento de la enferma incluyó elcontrol de la presión arterial, la utilización de drenajeventricular externo y la colocación de una válvulalumboperitoneal. En nuestro conocimiento esta es laprimera descripción en la literatura de la concurrenciade hemorragia intracraneal con la LPR. Este casofue satisfactoriamente tratado con un buen resultado,haciendo que la sospecha y el conocimiento de esta posible fatal complicación y su correcto tratamientosea importante para neurocirujanos, neurólogos eintensivistas (AU)

Apoplejía hipofisaria como presentación de recurrencia de craneofaringioma / Pituitary apoplexy as the presenting symptom of a recurrent craniopharyngionma

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Trapped fourth ventricle treated with shunt placement in the fourth ventricle by direct visualization with flexible neuroendoscope.

Shunt placement was the most common procedure used for ventricular dilatation, but in many neurosurgical centers it has been substituted by flexible neuroendoscope; however, none of them had solved the problem of the trapped and dilated fourth ventricle. The combination of the ventricle-peritoneal catheter placement in the center of the fourth ventricle by direct visualization with a flexible neuroendoscope using a single coronal burr-hole has solved this problem. Eleven patients with a trapped fourth ventricle, with previous third ventriculostomy and aqueductal plasty, were treated with this procedure; all patients were evaluated clinically and with computed tomography 8 to 24 months (mean, 18 months) later. Here, we describe the technical procedure.