Aneurysm Remnants after Flow Diversion: Clinical and Angiographic Outcomes.

BACKGROUND AND PURPOSE: Flow diversion is an established method to treat complex intracranial aneurysms. The natural history of flow-diversion treatment failure resulting in aneurysm remnants is not well-defined. We aimed to delineate the clinical and angiographic features of this entity. MATERIALS AND METHODS: Review of a prospectively maintained Pipeline Embolization Device data base from inception to October 2017 was performed for aneurysms that demonstrated residual filling on follow-up imaging. Procedural and follow-up clinical details were recorded. Independent, blinded, angiographic assessment of occlusion was performed on the basis of the O'Kelly-Marotta scale. Aggregated outcomes were analyzed using the Fisher exact and Mann-Whitney U tests for categoric and continuous variables, respectively (statistical significance, α = .05). RESULTS: During the study period, 283 sequential patients were treated; 87% (246/283) were women. The median patient age was 55 years (interquartile range, 47-65 years). Six-month follow-up imaging was available in 83.7% (237/283) of patients, which showed 62.4% (148/237) complete occlusion (class D, O'Kelly-Marotta grading scale). Adjunctive coiling (P = .06), on-label Pipeline Embolization Device use (P = .04), and multiple device constructs (P = .02) had higher rates of complete occlusion at 6 months. Aneurysm remnants were identified in 25 cases on long-term follow-up imaging (median, 16 months; interquartile range, 12-24 months). No patient with an aneurysm remnant after flow diversion presented with delayed rupture or other clinical sequelae, with a median clinical follow-up of 31 months (interquartile range, 23-33 months). CONCLUSIONS: Aneurysm remnants after flow diversion are infrequent with minimal clinical impact. When appropriate, the presence of overlapping devices and possibly adjunctive coiling may result in higher rates of complete occlusion.

Stroke etiology and collaterals: atheroembolic strokes have greater collateral recruitment than cardioembolic strokes.

BACKGROUND AND PURPOSE: Chronic hypoperfusion from athero-stenotic lesions is thought to lead to better collateral recruitment compared to cardioembolic strokes. It was sought to compare collateral flow in stroke patients with atrial fibrillation (AF) versus stroke patients with cervical atherosclerotic steno-occlusive disease (CASOD). METHOD: This was a retrospective review of a prospectively collected endovascular database. Patients with (i) anterior circulation large vessel occlusion stroke, (ii) pre-treatment computed tomography angiography (CTA) and (iii) intracranial embolism from AF or CASOD were included. CTA collateral patterns were evaluated and categorized into two groups: absent/poor collaterals (CTA collateral score 0-1) versus moderate/good collaterals (CTA collateral score 2-4). CT perfusion was also utilized for baseline core volume and evaluation of infarct growth. RESULTS: A total of 122 patients fitted the inclusion criteria, of whom 88 (72%) had AF and 34 (27%) CASOD. Patients with AF were older (P < 0.01) and less often males or smokers (P = 0.04 and P < 0.01 respectively). Baseline National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were comparable between groups. Collateral scores were lower in the AF group (P = 0.01) with patients having poor collaterals in 28% of cases versus 9% in the CASOD group (P = 0.03). Mortality rates (20% vs. 0%; P = 0.02) were higher in the AF patients whilst rates of any parenchymal hemorrhage (6% vs. 26%; P < 0.01) were higher in the CASOD group. On multivariable analysis, CASOD was an independent predictor of moderate/good collaterals (odds ratio 4.70; 95% confidence interval 1.17-18.79; P = 0.03). CONCLUSIONS: Atheroembolic strokes seem to be associated with better collateral flow compared to cardioembolic strokes. This may in part explain the worse outcomes of AF-related stroke.

Treatment of wide-necked aneurysms with the Low-profile Visualized Intraluminal Support (LVIS Jr) device: a multicenter experience.

BACKGROUND: The Low-profile Visualized Intraluminal Support (LVIS) Junior stent is newly approved for the treatment of wide-necked intracranial aneurysms. OBJECTIVE: To report our multicenter experience with use of the LVIS Jr device. METHODS: The neurointerventional databases of the participating institutions were retrospectively reviewed for aneurysms treated with LVIS Jr from the time of Food and Drug Administration approval until February 2016. All patients in the study period were included. Clinical presentation, aneurysm location, aneurysm size, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis. RESULTS: Eighty-five patients (54 female and 31 male) met the inclusion criteria for the study. Sixty-eight (80%) of the aneurysms were unruptured and the remainder were ruptured. The most common location of the treated aneurysms was anterior communicating artery (36%), middle cerebral artery bifurcation (22%), and basilar terminus (15%). The mean aneurysm size was 6.1 mm. The mean minimum parent vessel size was 2.3 mm. The LVIS Jr was successfully deployed in all but one case (99%). Initial angiographic results demonstrated Roy-Raymond class 1-2 occlusions in 61/84 patients (73%). At 6 months, 85% of the patients seen at follow-up had Roy-Raymond class 1-2 aneurysm occlusion. No procedure-related deaths occurred. Two cases of procedure-related complications (intraprocedural rupture and delayed rupture at day 2) were seen, leading to permanent neurologic morbidity. Both these cases were in patients with ruptured aneurysms. CONCLUSIONS: The LVIS Jr is a technically feasible, safe, and effective treatment for wide-necked intracranial aneurysms. Early results are promising but will need to be corroborated with longer-term follow-up.

Age increases the risk of immediate postoperative dysphagia and pneumonia after odontoid screw fixation.

INTRODUCTION: Type II odontoid fractures are the most common spinal fracture in the elderly population and may be managed with halo immobilization, posterior fusion, and anterior odontoid screw fixation. Anterior odontoid screw fixation has several advantages over posterior fusion, including: reduced surgical time, decreased post-operative pain, preserved range of motion, earlier mobilization, and decreased postoperative narcotic requirement. We review our experience using anterior odontoid screw fixation in type II odontoid fractures in the elderly and non-elderly populations. METHODS: Demographic and outcome data were retrospectively collected in 30 consecutive patients with type II odontoid fractures treated with anterior odontoid screw fixation. RESULTS: Mean patient age was 70.7 (range 20-92); 18 of the patients were male and 12 were female. All patients had successful placement of a single anterior odontoid screw without intra-operative complication. Complications included pneumonia in nine patients (30%), gastrostomy tube placement due to patient failing swallow evaluation in 13 patients (43%), and vocal cord paralysis in one patient (3.3%). Patients over the age of 75 accounted for 12 of the 13 (92%) gastrostomy tube placements and eight of the nine (88.9%) pneumonias, respectively. The difference in rates of gastrostomy tube placement and pneumonia for the older patients were both found to be statistically significant with P<.0001 for gastrostomy tubes and P<.02 for pneumonias. CONCLUSIONS: Anterior odontoid screw fixation is an effective treatment option for patients with Type II odontoid fractures. In the elderly population, however, the benefits of the procedure must be weighed against the risks of postoperative dysphagia requiring gastrostomy and pneumonia.

Endovascular treatment of acute carotid occlusion.

OBJECTIVES: Acute cervical carotid occlusion is one of the most challenging scenarios encountered in endovascular stroke treatment. PATIENTS AND METHODS: A retrospective analysis of 11 consecutive non-dissection stroke patients with concomitant cervical carotid and intracranial occlusion treated with intraarterial (IA) mechanical thrombectomy and/or pharmacologic thrombolysis over five years at two academic hospitals was performed. Data was analyzed using Fisher's exact test. RESULTS: Patients included 3 females and 8 males. Average age was 64.7 years (range 30-94 years). All patients had both cervical carotid and intracranial occlusions. Intracranial occlusion involved the internal carotid artery in 7 patients and the middle cerebral artery in 4 patients. All of the patients received intracranial IA Tissue Plasminogen Activator (tPA). Six patients received carotid stents for cervical occlusion as part of their treatment. Five patients received only IA tPA via collateral circulation. Of the patients receiving stents, 5 of 6 (83.3%) had successful recanalization (Thrombolysis in Cerebral Ischemia 2b or 3 flow). Only 1 of 5 (20%) patients who did not receive stents prior to intracranial treatment had successful recanalization. The difference in recanalization rates approached statistical significance (p=.08). There were 4 total in-hospital mortalities: 2 in the group that received stents prior to thrombolysis and 2 in the non-stent group. There were 2 clinically significant hemorrhages in the study, both in the stent group. CONCLUSIONS: Revascularization of the cervical carotid occlusion prior to treatment of the intracranial occlusion led to increased rates of recanalization in patients with tandem extracranial and intracranial occlusions. Whether a clinical benefit can be consistently derived likely relies on other factors, including the evaluation of cerebral perfusion.

The clinical and radiographic importance of distinguishing partial from near-complete reperfusion following intra-arterial stroke therapy.

BACKGROUND AND PURPOSE: Reperfusion following intra-arterial stroke therapy is associated with improved clinical outcomes. However, the degree of reperfusion needed to achieve successful outcomes is unknown. The purpose of this analysis was to determine whether the degree of reperfusion has an impact on final infarct volumes and clinical outcomes. MATERIALS AND METHODS: A retrospective analysis identified 88 consecutive patients who underwent intra-arterial therapy for acute anterior circulation stroke. Reperfusion was graded by using the TICI scale into none (TICI 0 or 1), partial (TICI 2a), or near-complete (TICI 2b/3). Baseline characteristics were compared. For each of these groups, we compared discharge disposition and final infarct volumes. RESULTS: Near-complete, partial, and no reperfusion occurred in 44.3%, 26.1%, and 29.6% of patients, respectively. Baseline characteristics were similar across all 3 groups. The median NIHSS score was 15. Significant differences in discharge disposition were seen, with 41.0% of the TICI 2b/3 group discharged home versus 17.4% of TICI 2a and 7.7% of TICI 0/1. In-hospital mortality was 12.8% for TICI 2b/3 compared with 39.1% for TICI 2a and 34.6% for TICI 0/1. Patients with near-complete reperfusion were significantly more likely to have infarct volumes ≤70 mL (OR = 12.1; 95% CI, 2.7-54.2), compared with patients with partial reperfusion (OR = 2.2; 95% CI, 0.5-9.6). CONCLUSIONS: Significant differences exist in outcomes and infarct volumes between partial (TICI 2a) and near-complete (TICI 2b/3) reperfusion following intra-arterial stroke therapy. Further trials should separately report these groups to facilitate comparison among treatment paradigms.

Epidemiology of psychotherapeutic drug use in older adults.

Those over 65 years of age constitute nearly 13% of the United States population. This age group, however, consumes three times their number of prescribed and over-the-counter remedies. In fact, nearly 30% of all prescriptions and 40% of over-the-counter remedies are consumed by older adults. This is also the population most sensitive to the side effects of drugs and, in particular, to the mood- or mind-altering properties of commonly prescribed and over-the-counter remedies. This article discusses medication usage among older adults with a special focus on various classes of psychotherapeutic agents- their uses, potential abuses, and special hazards.