Epidural anesthesia causes outbreak of mycotic aneurysms: complications of Fusarium solani meningitis.

BACKGROUND: A health advisory was issued in response to a fungal meningitis outbreak linked to epidural anesthesia exposure in two plastic surgery clinics in Mexico, from January 1 to May 13, 2023. This descriptive analysis describes the neuroendovascular and neurosurgical observations and management of patients treated at a single stroke center located along the US-Mexico Border. METHODS: We conducted a retrospective chart review of fungal meningitis patients presenting between April and July 2023. RESULTS: Among the patients diagnosed with fungal meningitis (n=12), the majority (n=11) were afflicted with angio-invasive Fusarium solani. 83% received dual antifungal therapy, with 40% initiated on alternate-day intrathecal amphotericin B. Diagnostic cerebral angiography was performed on all patients, revealing aneurysms in 58% of cases, predominantly within the posterior circulation, notably the basilar artery, with a median size of 4.2 mm (IQR 3.3-4.8). Treatment strategies included flow diversion (70%) and primary coiling (14%) for aneurysms. Ventriculostomy placement was undertaken in 67% of patients, with 37.5% of these requiring conversion to ventriculoperitoneal shunts. Subarachnoid hemorrhage development was uniformly associated with 100% mortality. CONCLUSIONS: In patients presenting with Fusarium solani meningitis, weekly angiographic surveillance proved instrumental for monitoring aneurysm and vasospasm development. Conventional angiography outperformed CT angiography due to its enhanced ability to detect small aneurysms. A proactive approach to aneurysm treatment is advocated, given their elevated rupture risk. While our findings suggest the potential reversibility of angiographic vasospasm with effective antifungal treatment, we acknowledge the challenge of drawing definitive conclusions based on a limited sample size.

Augmented reality enhanced tele-proctoring platform to intraoperatively support a neuro-endovascular surgery fellow.

BACKGROUND: Remote tele-proctoring has been conducted in neuro-endovascular surgery, however, evidence to support its use in the fellowship training is limited. We demonstrate a novel augmented reality tele-proctoring platform to enable a remote attending to guide a fellow. METHODS: A consecutive series of neuro-endovascular cases were performed by a neuro-endovascular fellow with remote guidance from an attending surgeon. The fellow and attending were connected using a commercially available cloud-based platform designed to capture and stream up to four live video feeds from a clinical environment to a remote user. In this setting, two video streams were obtained directly from the anteroposterior and lateral cameras on the biplane. Additional video of the operator from a telescopic camera was streamed live to the remote attending surgeon. The attending could provide immediate vocal feedback and also deploy the platform's augmented reality tools to communicate with the fellow in the angiography suite. RESULTS: A total of 10 cases were performed on eight patients utilizing the cloud-based tele-proctoring platform to facilitate instruction. The series included diagnostic angiograms and interventions such as intracranial balloon angioplasty, carotid stenting, and intracranial stenting. All cases were a technical success. No complications or deaths occurred. When compared to similar cohort of 10 cases prior to these which utilized a traditional instruction paradigm; we saw no differences in contrast use (p = 0.38), fluoroscopy time (p = 0.85), or technical success. CONCLUSIONS: This study demonstrates successful use of an augmented reality tele-proctoring platform to guide a neuro-endovascular fellow through complex neuro-interventional procedures from a remote setting.

Therapeutic Benefit of Cilostazol in Patients with Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis of Randomized and Nonrandomized Studies.

OBJECTIVE: To assess the effectiveness of cilostazol, a selective inhibitor of phosphodiesterase type III, in preventing cerebral ischemia related to cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). METHODS: A total of six clinical studies met the inclusion criteria and were included in the meta-analysis. We calculated pooled risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. The primary endpoint was cerebral ischemia related to vasospasm. Secondary endpoints were angiographic vasospasm, new cerebral infarct, mortality, and death or disability at the final follow-up. RESULTS: A total of 136 (22%) of 618 subjects (38 and 98 assigned to cilostazol and control treatments, respectively) with SAH developed cerebral ischemia related to vasospasm. The risk of cerebral ischemia related to vasospasm was significantly lower in subjects assigned to cilostazol treatment (RR 0.43; 95% CI 0.31-0.60; p< 0.001). The risks of angiographic vasospasm (RR 0.67, 95% CI 0.54-0.84, p< 0.001 ) and new cerebral infarct (RR 0.37, 95% CI 0.24-0.57, p< 0.001) were significantly lower in subjects assigned to cilostazol treatment. There was a significantly lower rate of death or disability in subjects assigned to cilostazol treatment at follow-up (PR 0.55, 95% 0.39-0.78, p = 0.001). CONCLUSION: The reduction in rates of cerebral ischemia related to vasospasm and death or disability at follow-up support further evaluation of oral cilostazol in patients with aneurysmal SAH in a large randomized clinical trial.

Multidisciplinary protocol for rapid head computed tomography turnaround time in acute stroke patients.

BACKGROUND: The door-to-computed tomography (CT) head reporting time is an essential step to determining eligibility for thrombolysis in acute stroke patients, but the specific components of the process have not been reported in detail. METHODS: We performed a retrospective cross-sectional analysis of the prospectively collected Get-With-The-Guidelines database in our comprehensive stroke center to evaluate the effect of a structured multidisciplinary protocol on head CT times in acute stroke patients under consideration for thrombolysis. RESULTS: The median CT turnaround time in the first 6-month period was 27 (interquartile range [IQR], 27) and decreased in all subsequent periods after implementation of a formal protocol to 18 (IQR, 12; range, 17-20 minutes; P < .0001 for all pairwise comparisons). The median CT turnaround time was 18 (IQR, 12) versus 20 (IQR, 14) minutes for patients with admission diagnosis of stroke (n = 1123) versus nonstroke (n = 685; P < .0001), respectively. CONCLUSIONS: A structured multidisciplinary protocol for obtaining acute stroke protocol head CT scan was associated with reduced CT turnaround time over the study period. Prospective studies should be done to determine if implementation in other stroke centers confirms the effectiveness of our protocol.

Multi-modality neuro-monitoring: conventional clinical trial design.

Multi-modal monitoring has become an integral part of neurointensive care. However, our approach is at this time neither standardized nor backed by data from randomized controlled trials. The goal of the second Neurocritical Care Research Conference was to discuss research priorities in multi-modal monitoring, what research tools are available, as well as the latest advances in clinical trial design. This section of the meeting was focused on how such a trial should be designed so as to maximize yield and avoid mistakes of the past.

Aspirin treatment failure and the risk of recurrent stroke and death among patients with ischemic stroke.

BACKGROUND: The prognostic value of occurrence of ischemic stroke in a patient despite aspirin treatment (aspirin treatment failure) is not known. Our objective was to determine if aspirin treatment failure predicts recurrent ischemic stroke and/or death. METHODS: We performed a post-hoc analysis of data from the National Institute of Neurological Disorders and Stroke (NINDS) intravenous recombinant tissue plasminogen activator (rt-PA) trial and the Trial of ORG 10172 in Acute Stroke Treatment (TOAST). Multivariate analysis was used to calculate the odds ratio (OR) of recurrent stroke and recurrent stroke or death for aspirin treatment failure patients for the duration of available follow-up (3 months for TOAST patients; 12 months for NINDS rt-PA trial patients). RESULTS: The rate of aspirin treatment failure was 40% and 35% among 1275 patients and 624 patients recruited in the TOAST and NINDS rt-PA trials, respectively. The risk of stroke and death at 3 months and 1 year was not higher among patients classified as aspirin treatment failures among the TOAST (OR 1.1; 95% confidence interval [CI] 0.8-1.6; P = .7) or NINDS rt-PA trial patients (OR 0.8; 95% CI 0.6-1.3; P = .4), respectively. In subgroup analysis, aspirin treatment failure was not found to be associated with recurrent stroke or with the combined endpoint of stroke and death among categories defined by etiologic subtype, including those with large artery atherosclerosis. CONCLUSIONS: In a post-hoc analysis of 2 randomized ischemic stroke trials, aspirin treatment failure was not found to be associated with an increased risk of recurrent stroke or death.

Intra-arterial tenecteplase for treatment of acute ischemic stroke: feasibility and comparative outcomes.

OBJECTIVE: Tenecteplase (TNK) is a third-generation thrombolytic agent. We evaluated the safety and feasibility of intra-arterial (IA) administration of TNK in patients with acute ischemic stroke. METHODS: Patients who received endovascular treatment for acute ischemic stroke were identified from prospectively collected databases at three university hospitals. We compared clinical and radiological outcomes of patients treated with TNK to those treated with other IA thrombolytics or mechanical thrombectomy alone. Primary outcome measures were favorable functional outcome at 30 days (modified Rankin Scale score of 0-2), and rate of intracranial hemorrhage (ICH). Early neurological improvement, angiographic recanalization, time to recanalization, and mortality at 30 days were additional outcome measures. RESULTS: We identified 114 patients (mean age 67 ± 15 years, 54 were women). Thirty-three patients received IA TNK, 48 received alteplase (n = 11) or reteplase (n = 37), and 33 patients had mechanical thrombectomy alone. Stroke severity was similar among the three groups. No difference between the groups was found in the secondary outcome measures and ICH. Borderline statistical significance was seen toward favorable functional outcome at 1 month in the TNK-treated patients [odds ratio (OR) = 2.8; 95% confidence interval (CI) .96-8.1, P = .063 vs. other thrombolytics, and OR = 3.0, 95% CI .97-9.5, P = .06 vs. mechanical thrombectomy alone]. CONCLUSION: Our study demonstrates that administration of IA TNK in acute stroke is safe and results in rates of favorable outcomes that are comparable to those observed with currently used drugs. Additional studies are needed to further determine the safety and efficacy of IA TNK in acute stroke treatment.

Estimated prevalence of acoustic cranial windows and intracranial stenosis in the US elderly population: ultrasound screening in adults for intracranial disease study.

BACKGROUND: Intracranial atherosclerosis is an important etiology of stroke in the USA, but its prevalence in the general population remains unknown. This study was performed to determine the feasibility of transcranial Doppler ultrasound (TCD) for general population screening and to estimate the prevalence of intracranial stenosis in the USA. METHODS: We used a public database to randomly select 99 subjects aged 65-84 years residing in a well-defined geographic area. For all subjects clinical history was reviewed, blood pressure was recorded and TCD examination was performed to identify intracranial stenosis. RESULTS: The mean age of subjects was 72 years, 42 were men, and 17 were African-Americans. All acoustic windows were present in 77 subjects. After multivariate adjustment, the odds of absence of a bone window were higher in African-Americans [odds ratio (OR) 6.0, 95% confidence interval (CI) 1.8-2.0], nonsmokers (OR 3.1, 95% CI 1.0-9) and those with a high BMI (9% higher odds per index point). Among 77 subjects who had all acoustic windows present, intracranial stenosis of >50% was identified in 6.5%, and intracranial stenosis of any severity was identified in 16% of the persons. Intracranial stenosis was most prevalent in the middle cerebral artery (6%). CONCLUSION: Presence of acoustic windows is associated with vascular risk factors. Based on the high prevalence of significant intracranial stenosis in the US elderly population, it is feasible and important to perform a large-scale population-based study for this disease entity.

Intravenous recombinant tissue plasminogen activator administered after 3 h following onset of ischaemic stroke: a metaanalysis.

OBJECTIVE: To assess the efficacy of intravenous recombinant tissue plasminogen activator administered after 3 h following onset of ischaemic stroke. BACKGROUND: Some recent data indicate that treatment with intravenous recombinant tissue plasminogen activator may be beneficial even when administered to ischaemic stroke patients beyond 3 h from symptom onset. METHODS: We searched the medical literature using the MEDLINE, BIOSIS, and Cochrane databases for pertinent publications from 1966 to 2008 using the keywords 'alteplase', 'tissue plasminogen activator', and 'stroke'. Among the retrieved publications, we selected randomised controlled trials that administered recombinant tissue plasminogen activator during 3-6 h after symptom onset in patients with acute ischaemic stroke. We evaluated the effect of intravenous recombinant tissue plasminogen activator (compared with placebo) on the rate of good functional outcome (determined by modified Rankin Scale of 0-1) and mortality at three-months. A subset analysis was performed according to time of administration of intravenous recombinant tissue plasminogen activator (3-4·5 and 4·5-6 h). Odds ratios of individual trials were pooled using a random effects model. RESULTS: We analysed four randomised trials totaling 2104 patients (1053 control and 1051 recombinant tissue plasminogen activator-treated patients). Patients that received intravenous recombinant tissue plasminogen activator at 3-6 h following onset of symptoms had a significantly higher rate of favourable neurological outcome over the patients that received placebo (odds ratio 1·24, 95% confidence intervals 1·04-1·47, P=0·02). Treatment within the 3-4·5 time window was significantly associated with higher rate of favourable neurological outcome (OR 1·27, 95% confidence interval 1·01-1·60), but not for the 4·5-6 time window (OR 1·10, 95% confidence interval 0·75-1·51). There was no difference in mortality between patients that received intravenous recombinant tissue plasminogen activator than the patients that received pharmacologic placebo (OR 1·14, 95% confidence interval 0·76-1·70). CONCLUSIONS: Treatment with intravenous recombinant tissue plasminogen activator from 3-4·5 h following symptom onset is associated with an increased rate of favourable outcome at 90-days in this analysis. Treatment with intravenous recombinant tissue plasminogen activator beyond 4·5 h did not show a benefit; however, improved patient selection is needed for future studies.

Comparison of partial (.6 mg/kg) versus full-dose (.9 mg/kg) intravenous recombinant tissue plasminogen activator followed by endovascular treatment for acute ischemic stroke: a meta-analysis.

BACKGROUND: In the treatment of acute ischemic stroke, intravenous (IV) recombinant tissue plasminogen (rt-PA) and intraarterial (IA) interventions are often combined. However, the optimal dose of IV rt-PA preceding endovascular treatment has not been established. METHODS: Studies that used combined IV and IA thrombolysis were identified from a search of the MEDLINE, PubMed, and Cochrane databases. We compared the rates of angiographic recanalization, symptomatic intracerebral hemorrhage (sICH), and favorable functional outcome between patients who had been treated with .6 mg/kg IV rt-PA and those who had received .9 mg/kg rt-PA. RESULTS: Eleven studies met our criteria. In 7 studies, .6 mg/kg IV rt-PA had been administered to 317 patients, whereas 140 patients in 4 studies had received .9 mg/kg of IV rt-PA. The weighted mean of median National Institutes of Health Stroke Scale score at presentation was 18.3 in the .6 mg/kg group (median range 9-34), and 17.3 in the .9 mg/kg group (median range 4-39). Patients in the .9 mg/kg group had higher rates of favorable outcome [odds ratio (OR)=1.60, 95% confidence interval (CI)=(1.07-2.40), P=.022] and similar rates of sICH [OR=.86 (95% CI .41-1.83), P=.70]. Depending on the statistics used, the higher angiographic recanalization rate among patients treated with .9 mg/kg was significant (P=.03, events/trial syntax logistic regression) or borderline significant (P=.07, random effects model). CONCLUSION: Our analysis suggests that using .9 mg/kg IV rt-PA prior to IA thrombolysis is safe and may be associated with higher recanalization rates and better functional outcome at 3 months.

Safety and tolerability of high-intensity anticoagulation with bivalirudin during neuroendovascular procedures.

BACKGROUND: Bivalirudin (Angiomax) is a direct thrombin inhibitor used in interventional cardiology due to its several distinct advantages over heparin, most notably a shorter half-life and a potentially superior safety profile. Bivalirudin is also safe to use in patients with active or remote heparin-induced thrombocytopenia. Our objective was to evaluate the safety and tolerability of high-intensity anticoagulation using bivalirudin during neuroendovascular procedures. METHODS: The bivalirudin dosing regimens reported in the cardiac literature were modified empirically for two different activated clotting time (ACT) target ranges. The low-dose protocol (ACT of 250 to 300 s) was used for embolization procedures and the high-dose protocol (ACT of 300-350) was employed for angioplasty and stent placement. The bivalirudin treated patients were matched for age, gender, and type of procedure with a random sample of patients who underwent neuroendovascular procedures with the standardized heparin protocol. The thromboembolic and hemorrhagic complications were compared between the two groups and bleeding complications were categorized as major (hemorrhage that was intra-cerebral or resulted in Hb decrease ≥ 5 g/dl), minor, or insignificant. RESULTS: Bivalirudin was used in 30 patients with high-dose and low-dose bivalirudin protocols used in 26 and 4 patients, respectively. These were compared to the 60 control patients who received heparin. There were no bleeding or thromboembolic complications in the bivalirudin treated patients; however one patient reported a transient headache. In patients treated with heparin, one bleeding complication of a groin hematoma was reported. Also one patient was found to have left-arm weakness following the procedure which was attributed to a new small middle cerebral artery ischemic event. CONCLUSIONS: Our data supports that bivalirudin usage is likely a safe alternative to heparin for high-intensity anticoagulation in neuroendovascular procedures. Further studies are required for more definitive comparisons for efficacy and cost-effectiveness between the two agents.

Predictors and timing of neurological complications following intracranial angioplasty and/or stent placement.

BACKGROUND: Transient or permanent neurological complications can occur in the periprocedural period following intracranial angioplasty and/or stent placement. Which patients are at risk and the time period for maximum vulnerability among those who undergo intracranial angioplasty and/or stent placement have not been formally studied. OBJECTIVE: To assess the predictors and timing of neurological complications following intracranial angioplasty and/or stent placement in the periprocedural period in a consecutive series of patients. METHODS: We reviewed medical records and angiograms of consecutive patients treated with intracranial angioplasty and/or stent placement in 3 academic institutions. We evaluated the effect of demographic, clinical, intraprocedural, and angiographic risk factors on subsequent development of periprocedural neurological complications. Periprocedural neurological complications were defined as new or worsening transient or permanent neurological complications that occurred during or within 1 month of the procedure. We also recorded the timing and nature of neurological complications in the periprocedural period. RESULTS: A total of 92 patients were included in the study (mean age ± standard deviation: 59 ± 14 years; 59 were men). The overall rate of in-hospital neurological complications was 9.8% (9 of 92 patients). Eight out of 9 neurological complications occurred either during the procedure or within 6 hours thereafter. Presence of diabetes mellitus (P = .003) and use of balloon-expandable stent (P = .09) were associated with periprocedural neurological complications. The degree of pre- and post-procedure stenosis, morphological appearance, and length of lesion were unrelated to periprocedural complications. CONCLUSION: Patients with diabetes mellitus and those treated with balloon expandable stents are at high risk for periprocedural neurological complications. The first 6 hours following intracranial angioplasty and stent placement represent the period of highest risk.

Super-selective intra-arterial magnesium sulfate in combination with nicardipine for the treatment of cerebral vasospasm in patients with subarachnoid hemorrhage.

OBJECTIVES: To determine the safety and tolerability of super-selective intra-arterial magnesium sulfate in combination with intra-arterial nicardipine in patients with cerebral vasospasm after subarachnoid hemorrhage. METHODS: Patients were treated in a prospective protocol at two teaching medical centers. Emergent cerebral angiography was performed if there was either clinical, ultrasound, and/or computed tomographic (CT) perfusion deficits suggestive of cerebral vasospasm. Intra-arterial magnesium sulfate (0.25-1 g) was administered via a microcatheter in the affected vessels in combination with nicardipine (2.5-20.0 mg). Mean arterial pressures (MAP) and intracranial pressures (ICP) were monitored during the infusion. Immediate and sustained angiographic and clinical improvement was determined from post-treatment angiograms and clinical follow-up. Angiographic and clinical outcomes were compared to two published case series that has used nicardipine alone. RESULTS: A total of 58 vessels were treated in 14 patients (mean age 42 years; 11 women) with acute subarachnoid hemorrhage. The treatment was either intra-arterial nicardipine and magnesium sulfate alone or in conjunction with primary angioplasty. Forty vessels (69%) had immediate angiographic improvement with intra-arterial nicardipine and magnesium sulfate alone and 18 vessels (31%) required concomitant balloon angioplasty with complete reversal of the vasospasm. Retreatment was required in 13 vessels (22%) and the median time for retreatment was 2 days (range 1-13 days). Nicardipine treatment resulted in the reduction of MAP (12.3 mmHg, standard error [SE] 1.34, P-value <0.0001) without any significant change in ICP. Magnesium sulfate infusion was not associated with change in MAP or ICP. Among 31 procedures, immediate neurological improvement was observed in 22 (71%) procedures. In 12 (86%) patients, there were no infarctions in the follow-up CT scan acquired between 24 and 48 h. No statistical significant difference was observed in angiographic and clinical outcome of patients treated with the combination therapy in comparison with historical controls treated with nicardipine alone. CONCLUSION: Administration of intra-arterial magnesium sulfate in combination with nicardipine was well tolerated in patients with subarachnoid hemorrhage and cerebral vasospasm without a significant change in MAP and ICP. The efficacy of this combination therapy should be evaluated in a larger, controlled setting.

Premorbid use of statins is associated with higher recanalization rates in patients with acute ischemic stroke undergoing endovascular treatment.

BACKGROUND AND PURPOSE: Statins have been shown to have lipid-independent (pleiotropic) effects that may be beneficial in the management of vascular disease. We evaluated the effect of premorbid statin use on recanalization in patients with acute ischemic stroke undergoing endovascular treatment. METHODS: We retrospectively reviewed the charts of all patients who had undergone endovascular treatment for acute ischemic stroke at our institution. Computed tomography scans obtained after treatment were assessed for the presence of hemorrhagic transformation by an independent reviewer. The primary endpoint was partial or complete recanalization (at least 1 grade improvement in the Qureshi scale). Secondary endpoints were hemorrhagic transformation and neurological improvement. Multivariate analysis was performed to evaluate the effect of premorbid statin use after adjusting for potential confounders. RESULTS: Seventy-seven patients fulfilled our inclusion criteria (mean age 66 +/- 14, 38 were men) and among them 12 were on statins. The patients who were on statins had a higher recanalization rate (11/12 vs. 33/65, P= .02). This finding was confirmed by logistic regression analysis (odds ratio 17.25, 95% confidence interval 1.67-177.43). There was no significant difference between the two groups regarding neurological improvement and hemorrhagic transformation. CONCLUSION: This study demonstrates that patients on statins have higher recanalization rates when they undergo endovascular procedures for acute ischemic stroke.

Subacute recanalization and reocclusion in patients with acute ischemic stroke following endovascular treatment.

OBJECTIVE: To determine the rate of subacute recanalization and reocclusion and its effect on clinical outcomes among patients with ischemic stroke treated with endovascular treatment. Subacute recanalization and reocclusion occurring hours after completion of the intravenous or intra-arterial thrombolysis for acute ischemic stroke has been reported in anecdotal cases. METHODS: We performed cerebral angiography at 24 h to determine the status of occlusion after endovascular treatment (compared with immediate post-procedure angiogram) in a series of patients with ischemic stroke treated with endovascular treatment. Clinical and radiological evaluations were performed before and 24 h, and prior to discharge or 1-3 months after treatment. We performed multivariate analysis to evaluate the effect of subacute recanalization on clinical outcome graded using modified Rankin scale (mRS). Favorable outcome was defined by mRS of 0-2. RESULTS: A total of 56 patients (mean age 66 +/- 14 years; 22 were men) were analyzed. Subacute recanalization was observed in 16 (29%) patients and consisted of additional recanalization in 8 patients with early recanalization. Subacute recanalization was associated with a trend toward a higher rate of favorable outcome (Wald chi-square 3.3, P = 0.19) after adjusting for other covariates. Subacute recanalization was not associated with either neurological deterioration or symptomatic intracranial hemorrhage. Subacute reocclusion was observed in 5 (9%) patients. Subacute reocclusion was associated with a trend toward higher rate of neurological deterioration within 24 h (Wald chi-square 2.1, P = 0.15) after adjusting for other covariates. CONCLUSION: We found that new or additional recanalization occurs in one-fourth of the patients within 24 h of endovascular treatment and is not associated with any adverse consequences. Subacute reocclusion occurs infrequently after endovascular treatment.

Congenital subclavian steal associated with atresia of a left innominate artery.

A 22-year-old woman presented with a history of multiple spells of dizziness, difficulty speaking and occasional loss of consciousness lasting for up to one hour. The patient had been initially diagnosed with epilepsy and treated with Levatiracetam without success. The physical finding of decreased left carotid and radial pulses raised suspicion for Takayasu arteriitis and the patient was referred to our center for further evaluation including cerebral angiography. Angiography was performed via two 5-French sheaths placed in the right femoral and left radial arteries. The patient was found to have only two great vessels originating from the aortic arch, while the left carotid and subclavian arteries shared a common origin and did not communicate with the arch. There was prominent subclavian steal through the vertebrobasilar junction and through hyper-trophied spinal arteries. The right internal carotid artery supplied the left hemisphere through the anterior communicating artery and also provided flow to the posterior cerebral arteries. No vascular lesions were identified to support the diagnosis of vasculitis. Atresia of a left innominate artery is an extremely rare aortic arch variant1, 2 which, as in this case can lead to symptomatic subclavian steal. Surgical options are being discussed with the patient1.

Cutting balloon angioplasty for carotid in-stent restenosis: case reports and review of the literature.

Percutaneous stenting techniques are becoming more commonly used for treatment of carotid artery disease. One outcome of particular concern is in-stent restenosis. Indications for treatment of in-stent restenosis are not clearly defined. Use of traditional balloon angioplasty with or without stent placement is still considered the first option. Cutting balloon angioplasty has recently been used as an alternative treatment option for revascularization of in-stent restenosis with higher procedural success rates and without the use of additional stents. We report our experience with cutting balloon angioplasty in treating 2 patients with carotid in-stent restonosis, and review previous cases reported in the literature. A total of 16 patients have been treated with cutting balloon angioplasty. Among 11 patients for whom the clinical and angiographic information were available, 63% of patients were asymptomatic at the time of treatment, and more than 90% of patients showed either complete angiographic resolution or residual stenosis of less than 30%. Additional stent placement or angioplasty was required in only half of the patients, and 1 patient had recurrent stenosis. The review suggests that the procedure is safe and effective.

Covered stent graft for treatment of a pseudoaneurysm and carotid blowout syndrome.

BACKGROUND: Carotid blowout syndrome with pseudoaneurysm, a rapidly progressive pathology, may present emergently with massive oral hemorrhage. Use of an endograft prosthesis offers a treatment strategy with salvation of the carotid artery. CASE HISTORY: A 55 year old man with advanced squamous cell carcinoma of the head and neck presented with recurrent transoral hemorrhage, requiring endovascular treatment. TECHNICAL REPORT: Coil embolization was initially performed with little impact on the hemorrhage. A 7 x 40 mm Fluency® Plus covered stent (Bard Peripheral Vascular, Tempe, Arizona, USA) was placed and was supplemented by a second 8 x 40 mm Fluency Plus stent, with resulting cessation of active contrast extravasation. DISCUSSION: The risks and benefits of various treatment options of carotid pseudoaneurysm with blowout are discussed including the use or omission of antiplatelet and anticoagulant regimens, with reference to previously reported cases. CONCLUSION: Tandem, overlapping covered stent placement in the common carotid artery is feasible and offers a treatment option for carotid blowout syndrome. Risks of aggravation of hemorrhage versus long-term thromboembolic events without antiplatelet therapy must be considered in cases of active ongoing hemorrhage.

A case of dural arteriovenous fistula with retrograde intracranial venous flow.

PRESENTATION: Dural arteriovenous fistulae are relatively rare lesions which can present a variety of different symptoms ranging from tinnitus to devastating intracranial hemorrhage. For those fistulae that require treatment, therapy is available in a wide range of options. We describe the case of a 60-year old patient who presented with a right occipital lesion presumably secondary to a dural arteriovenous fistula of the right transverse-sigmoid junction. The patient underwent successful endovascular treatment of the fistula. DISCUSSION: The participants in our discussion present their thoughts on how to evaluate and when and how to treat dural arteriovenous fistulae.

Stent placement to treat positional occlusion of the vertebral artery: A report of two cases.

Positional occlusion of the vertebral artery is suspected in patients who present with posterior circulation signs or symptoms related to a specific head position. So far, the only reported treatment is surgery with the aim of relieving the position-dependent pressure that is applied to the vessel. We report on two patients who were treated successfully with stent placement.