Noninvasive Angiographic Results of Clipped or Coiled Intracranial Aneurysms: An Inter- and Intraobserver Reliability Study.

BACKGROUND AND PURPOSE: Noninvasive angiography is commonly used to assess the outcome of surgical or endovascular treatment of intracranial aneurysms in clinical series or randomized trials. We sought to assess whether a standardized 3-grade classification system could be reliably used to compare the CTA and MRA results of both treatments. MATERIALS AND METHODS: An electronic portfolio composed of CTAs of 30 clipped and MRAs of 30 coiled aneurysms was independently evaluated by 24 raters of diverse experience and training backgrounds. Twenty raters performed a second evaluation 1 month later. Raters were asked which angiographic grade and management decision (retreatment; close or long-term follow-up) would be most appropriate for each case. Agreement was analyzed using the Krippendorff α (αK) statistic, and the relationship between angiographic grade and clinical management choice, using the Fisher exact and Cramer V tests. RESULTS: Interrater agreement was substantial (αK = 0.63; 95% CI, 0.55-0.70); results were slightly better for MRA results of coiling (αK = 0.69; 95% CI, 0.56-0.76) than for CTA results of clipping (αK = 0.58; 95% CI, 0.44-0.69). Intrarater agreement was substantial to almost perfect. Interrater agreement regarding clinical management was moderate for both clipped (αK = 0.49; 95% CI, 0.32-0.61) and coiled subgroups (αK = 0.47; 95% CI, 0.34-0.54). The choice of clinical management was strongly associated with the size of the residuum (mean Cramer V = 0.77 [SD, 0.14]), but complete occlusions (grade 1) were followed more closely after coiling than after clipping (P = .01). CONCLUSIONS: A standardized 3-grade scale was found to be a reliable and clinically meaningful tool to compare the results of clipping and coiling of aneurysms using CTA or MRA.

Does Increasing Packing Density Using Larger Caliber Coils Improve Angiographic Results of Embolization of Intracranial Aneurysms at 1 Year: A Randomized Trial.

BACKGROUND AND PURPOSE: The impact of increased aneurysm packing density on angiographic outcomes has not been studied in a randomized trial. We sought to determine the potential for larger caliber coils to achieve higher packing densities and to improve the angiographic results of embolization of intracranial aneurysms at 1 year. MATERIALS AND METHODS: Does Embolization with Larger Coils Lead to Better Treatment of Aneurysms (DELTA) was an investigator-initiated multicenter prospective, parallel, randomized, controlled clinical trial. Patients had 4- to 12-mm unruptured aneurysms. Treatment allocation to either 15- (experimental) or 10-caliber coils (control group) was randomized 1:1 using a Web-based platform. The primary efficacy outcome was a major recurrence or a residual aneurysm at follow-up angiography at 12 ± 2 months adjudicated by an independent core lab blinded to the treatment allocation. Secondary outcomes included indices of treatment success and standard safety outcomes. Recruitment of 564 patients was judged necessary to show a decrease in poor outcomes from 33% to 20% with 15-caliber coils. RESULTS: Funding was interrupted and the trial was stopped after 210 patients were recruited between November 2013 and June 2017. On an intent-to-treat analysis, the primary outcome was reached in 37 patients allocated to 15-caliber coils and 36 patients allocated to 10-caliber coils (OR = 0.931; 95% CI, 0.528-1.644; P = .885). Safety and other clinical outcomes were similar. The 15-caliber coil group had a higher mean packing density (37.0% versus 26.9%, P = .0001). Packing density had no effect on the primary outcome when adjusted for initial angiographic results (OR = 1.001; 95% CI, 0.981-1.022; P = .879). CONCLUSIONS: Coiling of aneurysms randomized to 15-caliber coils achieved higher packing densities compared with 10-caliber coils, but this had no impact on the angiographic outcomes at 1 year, which were primarily driven by aneurysm size and initial angiographic results.

A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: Interim results from ISAT2.

BACKGROUND AND PURPOSE: Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined. METHODS: The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included. The primary endpoint is death or dependency on modified Rankin score (mRS>2) at 1 year. Secondary endpoints are 1 year angiographic results and length of hospital stay. RESULTS: An interim analysis was performed after 103 patients were treated from November 2012 to July 2017 in 4 active centers. Fifty-two of the 55 patients allocated to surgery were treated by clipping, and 45 of the 48 allocated to EVT were treated by coiling, with 3 crossovers in each arm. The main endpoint (1 year mRS>2), available for 76 patients, was reached in 16/42 patients allocated to clipping (38%; 95%CI: 25%-53%), and 10/34 patients allocated to coiling (29%; 17%-46%). One year imaging results were available in 54 patients: complete aneurysm occlusion was found in 23/27 patients allocated to clipping (85%; 67%-94%), and 18/27 patients allocated to coiling (67%; 47%-81%). Hospital stay exceeding 20 days was more frequent in surgery (26/55 [47%; 34%-60%]) than EVT (9/48 [19%; 10%-31%]). CONCLUSION: Ruptured aneurysm patients for whom surgical clipping may still be best can be managed in a randomized care trial, which is feasible in some centers. More participating centers are needed.

CT perfusion for confirmation of brain death.

SUMMARY: For pronouncing brain death, unlike CTP, the 2-phase CTA gives no functional information and is limited by inadvertent delay of the second acquisition, which may give false-negative results. The purpose of our study was to compare CTP and CTA derived from the CTP data with the Dupas and Frampas criteria for confirmation of brain death. A retrospective review of CTP in 11 consecutive patients for confirmation of brain death showed a sensitivity of 72.7% for 7- and 4-point scores, 81.8% for opacification of the ICV, and 100% for CTP scores in the brain stem. CTA obtained from the CTP data showed similar sensitivity in the diagnosis of brain death. This protocol also reduces the iodinated contrast dose and is less operator-dependent. The addition of the functional tools of CTP increased the sensitivity of CTA in the confirmation of brain death.

Angioarchitecture of brain AVM determines the presentation with seizures: proposed scoring system.

BACKGROUND AND PURPOSE: Seizures are a common presentation in patients with brain arteriovenous malformations, but the pathogenesis of seizures remains poorly understood. The purpose of our study was to analyze various morphologic and hemodynamic characteristics of unruptured BAVMs presenting primarily with seizures and, on the basis of these, to propose a scoring system to predict seizures in patients with BAVMs. MATERIALS AND METHODS: In a retrospective review of our BAVM data base from 2000 to 2009, after excluding patients with ruptured BAVMs, we classified patients into 2 groups, those with and without seizures at presentation. Clinical, angiographic, and hemodynamic characteristics on cerebral angiograms of all these patients were studied. The association between various angioarchitectural variables and seizure presentation was examined, and these results were used to guide the development of criteria to predict presentation with seizures. RESULTS: Of 1299 patients in our data base, we finally analyzed 33 patients with unruptured BAVMs with seizures and 45 patients with unruptured AVMs without seizures. Location, fistulous component in the nidus, venous outflow stenosis, and the presence of a long pial course of the draining vein were identified as the strongest predictors of seizures. The proposed scoring system had good predictability of presentation with seizures. CONCLUSIONS: Specific angioarchitectural characteristics of unruptured BAVMs may predict occurrence of seizures and may help in targeted treatment.

Amplatzer vascular plug for occlusion of parent artery in carotid blowout with active extravasation.

Carotid blowout is a devastating complication in patients with head and neck malignancy. Various treatments including high risk surgery, carotid stenting or carotid occlusion using either coils or detachable balloons have been described. The key for any treatment is the rapidity at which it can be performed. We describe treatment of common carotid blowout secondary to neoplastic infiltration using four Amplatzer vascular plugs deployed in less than ten minutes.

Long-term prospective follow-up of intracranial aneurysms treated with endovascular coiling using contrast-enhanced MR angiography.

BACKGROUND AND PURPOSE: Catheter angiography has been the criterion standard for follow-up evaluation of coiled intracranial aneurysms. In our center, CE-MRA has been used to evaluate aneurysm recanalization. Our aim was to investigate the feasibility and usefulness of a CE-MRA protocol for following patients with intracranial aneurysms treated with endovascular coiling. MATERIALS AND METHODS: From September 2003 to December 2006, 134 aneurysms were treated by endovascular coiling in 124 patients by using detachable coils. These patients were followed with CE-MRA at 3 months, 15 months, and 3 and 5 years. MRAs were analyzed by 2 interventional neuroradiologists. Findings were assigned to 3 categories: complete obliteration (class 1), residual neck (class 2), and residual aneurysm (class 3). RESULTS: Initially, CE-MRA demonstrated 67 (50%) complete obliterations (class 1), 57 (41.79%) residual necks (class 2), and 8 (5.97%) residual aneurysms (class 3). No patient experienced rebleed during the follow-up period. A total of 214 patient-years of follow-up were obtained (range, 0-53 months). Two (1.49%) patients died after the follow-up, and 11 (8.21%) patients were lost to follow-up. On follow-up, 76 (56.72%) patients showed stable results. Fifty-six (41.79%) aneurysms showed change in their obliteration pattern. Of these 56, 47 demonstrated recanalization and 9 (6.72%) showed further obliteration. Most of the aneurysms that showed change in their obliteration remained stable on follow-up. Only 11 (8.21% of the total and 23.4% of those who showed recanalization) patients underwent recoiling or clipping. CONCLUSIONS: CE-MRA can be used in routine practice to follow-up aneurysm recanalization noninvasively. CE-MRA permits close-interval follow-up and may show more filling of the aneurysm neck or sac than DSA.

CT Perfusion in Spinal Disease: an Adjunct Tool to Vertebral Body Biopsy.

Routine diagnostic techniques are inadequate for diagnosis of spinal diseases. The purpose of this study was to determine whether CT perfusion can differentiate inflammatory diseases like tuberculosis from neoplastic diseases of spine. Thirty-two patients with vertebral body lesions associated with paraspinal mass underwent CT guided bone biopsy and histopathological evaluation. CT perfusion was done in all patients before doing biopsy. Perfusion parameters like blood volume (BV), blood flow (BF) and time to peak (TTP) were calculated and correlated with histopathology. Statistical analysis was done using Mann-Whitney test. p value <0.05 was considered significant. Of 32 cases, 20 had tuberculous osteomyelitis and 12 neoplastic disease (seven metastasis, three plasmacytoma, one each lymphoma and chordoma). Mean rBF was [inflammatory lesions, 1.459 and neoplastic lesions, 18.080 (p<0.000). Mean rBV was (inflammatory disease, 2.8589 and neoplastic lesions, 12.2133 (p<0 .000)). Mean rTTP was [inflammatory pathology, 1.041 and neoplastic pathology, 0.703(p<0.079)]. This shows the deconvolution-based CTP technique's potential for noninvasive diagnosis of at least all inflammatory lesions affecting the spine that are associated with paraspinal mass. Validation of the use of deconvolution CTP parameters for differentiation of inflammatory from neoplastic pathology may permit this technique to be used as an adjunct tool when biopsy when routine imaging findings are inconclusive.

Spontaneous resolution of bilateral superior ophthalmic vein and cavernous sinus thrombosis. A case report.

Superior ophthalmic vein thrombosis is uncommon, and bilateral superior ophthalmic vein thrombosis is rarer still. The resolution of bilateral superior ophthalmic vein thrombosis takes a long time. The spontaneous resolution of bilateral superior ophthalmic vein thrombosis is not known and not reported in the literature so far. Here we present MRI of bilateral superior ophthalmic vein thrombosis and its spontaneous resolution.

Vertebral body signal changes in spinal cord infarction: histopathological confirmation.

Spinal cord infarctions are rare. They are difficult to diagnose clinically and remain undiagnosed even after extensive investigations. Magnetic Resonance (MR) features include hyperintensity of the cord on T2W images. Few cases of spinal cord infarction associated with vertebral body infarction are reported in the literature. We describe another five cases of spinal cord infarction with histopathological confirmation of the vertebral body signal changes. MR examinations of five patients who presented with acute spontaneous spinal cord syndrome were reviewed. Abnormal MR features of the spinal cord included signal changes within the parenchyma, best demonstrated on T2W images. These cord changes were associated with vertebral body T2 hyperintensity in all the patients and in one patient, the computed tomography guided biopsy of vertebral body lesion reported infarction. MR is sensitive to detect spinal cord infarctions and associated vascular and bony changes. The associated signal abnormalities in the bone marrow are a corroborative sign in the diagnosis of spinal cord infarction which was proved by histopathology.