Assessment of clot length with multiphase CT angiography in patients with acute ischemic stroke.

Introduction Existing stroke literature demonstrates that rapid recanalization of vessels improves long-term prognosis after acute ischemic stroke. However, further optimization of the speed of the thrombectomy procedure, used to recanalize a blocked vessel, is limited by our minimal knowledge of the clot dimensions pre-procedure. Knowing the clot dimensions would allow planning of the thrombectomy procedure with the appropriate size and length of stent retriever, and determination of the correct site of the stent deployment ensuring total coverage of the clot by the stent retriever. Methods We performed a feasibility study to assess if multiphase computed tomography angiography (mCTA) can be used to estimate clot length by comparing CTA imaging data with imaging data obtained from conventional digital subtraction angiography (DSA). A retrospective chart review was performed of patients with clots in the proximal middle cerebral artery and adequate collateral circulation, who underwent both mCTA and DSA. Results Clot length was not significantly different on 3D mCTA versus mCTA MIPs, nor was it significantly different on MIP mCTA versus DSA. Pathological evidence also supported our ability to measure clot length on mCTA. Conclusions We suggest that mCTA is a reliable and valid measure of clot length in acute ischemic stroke patients.

Canadian Registry of LVIS Jr for Treatment of Intracranial Aneurysms (CaRLA).

INTRODUCTION: Stents reduce the rate of angiographic recurrence of intracranial aneurysms. The newest stent for intracranial use is the Low-profile Visible Intraluminal Support device (LVIS Jr). OBJECTIVE: To assess the efficacy of the new stent in a multicenter retrospective registry. MATERIALS AND METHOD: Centers across Canada using LVIS Jr were contacted and asked to participate in a retrospective registry of consecutive patients treated with LVIS Jr for intracranial aneurysms between January 2013 and July 2015. RESULTS: A total of 102 patients, with saccular aneurysms in 100 patients (72 women; age range 21-78 years; mean 56.0 years; median 57.5 years) were treated with a LVIS Jr stent. The mean maximum diameter of the dome and neck of the aneurysm and dome to neck ratios were 8.3 mm±7.7 mm, 4.4 mm±1.9 mm, and 1.86±1.22, respectively. Angiographic complications arose in 23 patients, clinical complications in 9 patients, and only 3% of permanent neurological deficits occurred. Death occurred in 1 patient, unrelated to the stent. The ruptured status of the aneurysms (OR=3.29; p=0.046) and use of LVIS Jr for bailout (OR=2.54; p=0.053) showed a trend towards significant association with higher angiographic complications. At the last available follow-up, 68 class I, 20 class II, and 12 class III results were seen. CONCLUSIONS: The LVIS Jr stent is a safe and effective device for stent-assisted coiling, with 3% permanent neurological complications. Stent-assisted coiling continues to be technically challenging in cases of ruptured aneurysms and bailout situations.

Paradoxically Decreased Mean Transit Time in Patients Presenting With Acute Stroke.

OBJECTIVE: Computed tomography perfusion (CTP) has become a mainstay in acute stroke management. The aim of this study was to investigate the occurrence of an unreported phenomenon of a paradoxically decreased mean transit time (MTT) in the cerebral area of ischemia. METHODS: In this retrospective study, patients with an acute anterior circulation ischemic stroke were selected. Computed tomography perfusion diffusion maps of all patients were reviewed by 2 blinded and experienced neuroradiologists. RESULTS: A total of 31 patients were included in the study. Eighteen subjects (58%) had a paradoxical MTT perfusion map, whereas only 13 (42%) had an expected CTP profile. No significant associations between the paradoxical MTT perfusion and the size of the infarct, the side of the occlusion, or the age of the patients were observed. However, a trend in collateral circulation status and paradoxical MTT was noted. CONCLUSIONS: A paradoxical MTT response is a frequent finding in CTP analysis of patients with acute stroke. Its presence is not associated to the location or size of the affected cerebral territory and could be related to the presence of collateral circulation.

A novel mutation in the CSF1R gene causes a variable leukoencephalopathy with spheroids.

Hereditary diffuse leukoencephalopathy with neuroaxonal spheroids is a neurodegenerative disease associated with mutations in the colony-stimulating factor 1 receptor gene (CSF1R). A 44-year-old woman with a 7-year history of depression presented with neurological signs and a recent cognitive decline. The diagnosis of hereditary diffuse leukoencephalopathy with neuroaxonal spheroids was suspected based on the findings of a predominant frontal leukoencephalopathy and neuroaxonal spheroids on brain biopsy. She shares with her mother a novel CSF1R exon 18 missense mutation (c.2350G > A; p.V784M). The mother has a long-standing bipolar disorder and mild multifocal white matter abnormalities in her 70s. This is the first report of hereditary diffuse leukoencephalopathy with neuroaxonal spheroids due to this novel CSF1R missense mutation. Our report suggests that either marked intrafamilial variability or incomplete penetrance can be associated with CSF1R mutations. The observation of a small bone cyst in our patient supports the hypothesis that hereditary diffuse leukoencephalopathy with neuroaxonal spheroids and polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy may belong to a spectrum of overlapping phenotypes.

Milrinone and homeostasis to treat cerebral vasospasm associated with subarachnoid hemorrhage: the Montreal Neurological Hospital protocol.

INTRODUCTION: For the treatment of cerebral vasospasm, current therapies have focused on increasing blood flow through blood pressure augmentation, hypervolemia, the use of intra-arterial vasodilators, and angioplasty of proximal cerebral vessels. Through a large case series, we present our experience of treating cerebral vasospasm with a protocol based on maintenance of homeostasis (correction of electrolyte and glucose disturbances, prevention and treatment of hyperthermia, replacement of fluid losses), and the use of intravenous milrinone to improve microcirculation (the Montreal Neurological Hospital protocol). Our objective is to describe the use milrinone in our practice and the neurological outcomes associated with this approach. METHODS: Large case series based on the review of all patients diagnosed with delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage between April 1999 and April 2006. RESULTS: 88 patients were followed for a mean time of 44.6 months. An intravenous milrinone infusion was used for a mean of 9.8 days without any significant side effects. No medical complications associated with this protocol were observed. There were five deaths; of the surviving patients, 48.9 % were able to go back to their previous baseline and 75 % had a good functional outcome (modified Rankin scale ≤ 2). CONCLUSION: A protocol using intravenous milrinone, and the maintenance of homeostasis is simple to use and requires less intensive monitoring and resources than the standard triple H therapy. Despite the obvious limitations of this study's design, we believe that it would be now appropriate to proceed with formal prospective studies of this protocol.