The impact of a two-year long COVID-19 public health restriction program on mechanical thrombectomy outcomes in a stroke network.

OBJECTIVE: The purpose of this study was to evaluate the impact of COVID-19 pandemic public health restrictions on our drip and ship mechanical thrombectomy program in Santiago Chile. MATERIALS AND METHODS: This was a retrospective analysis of a prospectively collected database comparing two cohorts, one during a two-year period before COVID-19 and the second during the two years of the pandemic at our metropolitan stroke program. RESULTS: A total of 100 patients were included in the pre COVID-19 cohort (cohort 1) and 121 in the COVID-19 cohort (cohort 2). There was a significant difference between cohorts, with older patients, different occlusion sites and higher door to arterial puncture time during the COVID-19 period. A non-significant trend for worse 90-day outcomes and higher mortality was present in cohort 2. There were no statistical differences in safety treatment parameters. CONCLUSIONS: COVID-19 pandemic has had a measurable impact on our mechanical thrombectomy program. Results showed similarities to other reported Latin American series, where less robust health systems could adapt less efficiently compared to developed countries. After two years of public health restrictions, there were changes in the treatment population characteristics, delay in some internal management metrics and a non-significant trend to worse 90-day outcomes and higher mortality.

A novel self-expanding shape memory polymer coil for intracranial aneurysm embolization: 1 year follow-up in Chile.

BACKGROUND: Aneurysm recurrence remains a challenge when coiling cerebral aneurysms. Development of next generation coils has focused on accelerating thrombus maturation and increasing coil packing density. Ultra low density shape memory polymer is a novel embolic material designed for this purpose. The polymer is crimped over a platinum-tungsten coil for catheter delivery and self-expands to a predefined volume on contact with blood. METHODS: This prospective study in humans evaluated aneurysms 5-16 mm (inclusive) in diameter that were indicated for endovascular coil embolization. At least 70% coil volume was required to be shape memory polymer coils. Patients were followed-up according to standard of care for 12 months. RESULTS: Nine patients (89% women, mean age 55.8±11.7 years) were treated with shape memory polymer coils and completed 12 months of follow-up. Aneurysms were all unruptured and were in the ophthalmic segment of the internal carotid artery (n=7), posterior communicating artery, and anterior cerebral artery A1-A2 segment. Aneurysms were a mean of 7.8±2.9 mm in diameter (range 5.2-14.9 mm). The mean packing density based on unexpanded polymer was 17±6%. Packing density based on expanded polymer was 43±13%. At 12 months, no recurrence had occurred, and a Raymond-Roy occlusion classification of 1 (n=5) or 2 (n=4) was observed. No serious adverse events related to the study device occurred over the 12 months after the procedure. CONCLUSIONS: Shape memory polymer coils were safe and effective in treating intracranial aneurysms over 12 months in this first study in human subjects.

Breaking the breach in Latin America: A pilot study of mechanical thrombectomy in the public healthcare system in Chile.

BACKGROUND: Mechanical Thrombectomy (MT) is the standard of care for treatment of large vessel occlusion stroke. Until the beginning of 2020 MT was not funded nor widely implemented at the public healthcare level in Chile. OBJECTIVE: To describe the results of a pilot program created to provide access to public MT in Santiago - Chile. METHODS: Analysis from a prospectively collected database of MT cases performed between September 2017 and September 2019 in one center. A stroke network was developed with a single MT capable stroke center and five primary stroke centers. The primary efficacy endpoint was the rate of functional independence (mRS 0-2) at 90 days. Successful reperfusion was defined as 2 b-3 according to the thrombolysis in cerebral infarction scale. Safety outcomes include the rates of symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: A total of 100 patients were treated over the study period. Their mean age was 62.8 ± 11.8 years and median baseline National Institute of Health Stroke Scale (NIHSS) measurement was 17. Seventy-seven percent of the patients received intra venous thrombolysis. Successful reperfusion was achieved in 95% of the cases. NIHSS at 24 hours showed a median drop of 7 points from baseline (p < 0.00001) and 50% of the follow-up patients were functionally independent at 90 days. Symptomatic Intracerebral hemorrhage occurred in 5% of the patients and 90-day all case mortality was 11%. CONCLUSIONS: We demonstrated the feasibility of a publicly funded MT program in Chile, with similar results as other international randomized control trials.

Quantitative evaluation of arteriovenous malformation hemodynamic changes after endovascular treatment using parametric color coding: A case series study.

Background Brain arteriovenous malformations (AVMs) are complex vascular lesions. Endovascular treatment results are usually measured by calculating the volume reduction of the lesions. Nevertheless, vascular flow quantification seems a more physiologically accurate way of measuring endovascular results. We evaluated the use of parametric color coding (PCC) with digital subtraction angiography (DSA), in order to determine the feasibility of PCC to detect and measure the impact of AVM endovascular treatment-induced changes using real-time hemodynamic parameters. Methods and results Supratentorial brain AVM treatment was evaluated in 29 patients over the course of 38 sessions. Using regions of interest (ROIs) at the carotid siphon, arterial feeder, drainage vein and venous sinus, we found significant increase in time to peak (TTP) values at the arterial feeder, drainage vein and venous sinus. We compared TTP in four different embolization volume groups: I (0-25%), II (26-50%), III (51-75%) and IV (76-100%). We found significant differences between groups and a moderate correlation between embolization percentages, as well as an increase in TTP at the main vein ROI; but not in the arterial side or sinus. Conclusions Brain AVM endovascular treatment results can be quantified in vivo with PCC. PCC is capable of detecting hemodynamic changes after brain AVM endovascular treatment, that may reflect flow drop, and it is correlated with volume embolization.

Unusual origin of the left ophthalmic artery from the basilar trunk.

The formation of the ophthalmic artery (OA) is a complex process with two different proposed embryological steps for its development. Several anatomical variants have been described. We present a very unusual origin of the ophthalmic artery from the basilar trunk, in a 45-year-old male with a history of pontine hemorrhagic stroke. MRI and CTA showed evidence of previous hemorrhage in the pons and several intracranial arterial dysplastic dilatations. DSA confirmed several fusiform dilatations of the basilar trunk. In the left ICA, no ophthalmic artery was seen arising from the carotid siphon. The left ophthalmic artery arises from the basilar trunk and runs lateral to the cavernous sinus through the middle cranial fossa, entering the left orbit at the superior orbital fissure. The patient was treated conservatively. Two main theories for this anomaly are known, one from Lasjaunias and the other from Paget. To our knowledge, this basilar origin of the OA has only been described three times in the literature. For its origin, we propose a partial persistence of the trigeminal artery together with a dominance of the dorsal ophthalmic artery.

Middle cerebral artery occlusion with moyamoya-like vessels and aneurysms. A report of two cases.

We describe two cases of aneurysmal rupture in moyamoya-like vessels in middle cerebral artery occlusion. This phenomenon was previously described in severe steno-occlusive disease and accounts for the hemorrhagic presentation. To our knowledge, these are the second and third clinical cases published in modern neuroradiological literature.

Endovascular treatment of aneurysm arising from fenestration of the supraclinoid internal carotid artery--two case reports.

We report two cases of aneurysm located in a fenestration of the supraclinoid internal carotid artery, an extremely rare anatomical variant, and describe the feasibility of endovascular treatment using two different strategies applicable for each case. Each presented aneurysm had a particular location on the fenestration, which led to different endovascular approaches. In one case, the aneurysm arose from the proximal junction of fenestration, involving both of its limbs. For this aneurysm, the treatment strategy adopted aimed to achieve a selective exclusion. In the second case, two aneurysms arose from the minor limb of the fenestration, which could be entirely excluded, considering the absence of perforating arteries arising from that carotid segment. To our knowledge, these two cases are the first ICA fenestration aneurysms treated exclusively by endovascular approach, showing two treatment strategies using coils in association to two different endovascular devices (stent/TrisPan(®)).

[Cyanoacrylate pulmonary embolism after embolization of a cerebral arteriovenous malformation. Report of one case]. / Embolía pulmonar por cianoacrilato pos embolización de malformación arteriovenosa cerebral. Caso clínico.

Arterial embolization with cyanoacrylate is commonly used for the treatment of arteriovenous malformations. We report the case of a 40 years old man who four days after an embolization with cyanoacrylate, begins with cough, bloody sputum, and right hemithorax pleuritic pain. Pulmonary embolism was confirmed with chest X ray, CT scan and scyntigraphy. The patient received anticoagulation, with adequate response. The most common complications of cerebral embolization are related to central nervous system and pulmonary embolism is exceptional. Considering the high number of embolization procedures done nowadays, this complication must be borne in mind.

Embolia pulmonar por cianoacrilato pos embolización de malformación arteriovenosa cerebral: caso clínico / Cyanoacrylate pulmonary embolism after embolization of a cerebral arteriovenous malformation: report of one case

Arterial embolization with cyanoacrylate is commonly used for the treatment of arteriovenous malformations. We report the case of a 40 years old man who four days after an embolization with cyanoacrylate, begins with cough, bloody sputum, and right hemithorax pleuritic pain. Pulmonary embolism was confirmed with chest X ray, CT scan and scyntigraphy. The patient received anticoagulation, with adequate response. The most common complications of cerebral embolization are related to central nervous system and pulmonary embolism is exceptional. Considering the high number of embolization procedures done nowadays, this complication must be borne in mind.