A Simplified One-Size-Fits-All Approach to Carotid Stenting.

BACKGROUND: Carotid artery stenosis causes up to 20% of ischemic strokes. Stenting is used as an alternative to endarterectomy in symptomatic patients. Each commercially available stent offers numerous stent diameters/lengths. Most centers thus carefully match each individual stenosis to a specific stent length/diameter stent size. However, this process can be time-consuming and costly while the relative benefit of a custom stent sizing versus one-size-fits-all approach has not been well evaluated yet. We hypothesized that a 'one-size-fits-all' default approach to carotid stenting results in comparable results to a customized approach. METHODS: We conducted a descriptive retrospective cohort study on 154 patients who presented to our academic carotid revascularization clinic with symptomatic carotid artery stenosis who underwent carotid artery stenting for peri- and postprocedural carotid artery stenting complications. The primary outcomes were periprocedural (within 24 hours of the procedure) or postprocedural (within 30 days of the procedure) TIA, stroke, or death. The secondary outcome was the estimated degree of stenosis on follow-up ultrasound performed within 6 months of the procedure. RESULTS: The complication rate within the first 24 hours was 4.5% while that during the first 30 days postprocedure was 6.5%. Age over 80 and degree of stenosis on postprocedural cerebral angiogram were associated with an increased risk of complications. Severe restenosis was reported in 16.8% of patients within 6 months postprocedure. CONCLUSION: Our study suggests that using a simplified, one-size-fits-all, approach to carotid stenting results in safe and effective outcomes, suggesting an alternative to simplify a complex medical procedure.

Non-Hodgkins lymphoma of the nasal cavity: A case report.

We present a rare case of an 81-year-old woman presenting with acute left nasal blockage caused by a large nasal mass of unknown origin. The mass was subsequently diagnosed as diffuse large B-cell non-Hodgkin lymphoma (NHL). Nasal/paranasal space involvement in NHL is uncommon, representing only 0.2%-2% of cases. In this case, the nasal NHL mass exhibited a favorable prognosis, in contrast to previously reported sinonasal lymphomas with poor outcomes. The patient underwent excisional biopsy and was treated with 3 cycles of R-CHOP chemotherapy, resulting in complete resolution of the mass confirmed by a follow-up CT scan and no signs of disease after 1 year. Differentiating sinonasal lymphomas from other neoplasms can be challenging due to their variable morphology and location. Diffuse presentations of sinonasal lymphoma can aid in distinguishing them from discrete lesions associated with other sinonasal neoplasms. However, differentiation from acute invasive sinonasal infection remains difficult. MRI can help identify lymphomas through the characteristic hypointense T2 signal and diffusion restriction, with the combined use of CT to aid in differentiating masses of unknown morphology. Nonetheless, squamous cell carcinoma, which mimics lymphoma features on MRI, poses additional challenges to accurate identification. This case highlights the rarity of nasal NHLs, their potential for excellent prognosis, and the importance of diverse imaging techniques in their diagnosis and differentiation from other sinonasal pathologies.

Venous spot sign: Indicator of rapid hematoma expansion in venous thrombosis type of submission: Case reports.

BACKGROUND: The term "spot sign" was coined by Wada et al in 2007 and thought to be due to ongoing arterial bleeding in primary intraparenchymal haemorrhage (IPH).1 Spot sign has also been described in the context of intraventricular haemorrhage (IVH).2 Over the years arterial spot signs have been found to correlate with intraparenchymal hematoma expansion, worse clinical outcomes and increased risk of surgical intervention.3 We are describing a unique instance of a spot sign in venous sinus thrombosis that initially misled the clinical diagnosis. CASE PRESENTATION: An 83-year-old woman on dual antiplatelet therapy, with a history of minor stroke, presented with sudden right-sided weakness and dysarthria. Serial CT brain imaging revealed rapidly enlarging intraparenchymal haemorrhage (IPH). Contrast enhanced CT displayed multiple spot signs typically associated with arterial bleeding pattern. Initially possibility of antithrombotic related IPH was kept, however venogram confirmed venous pathology with focal superior sagittal sinus thrombosis (SSS). Unfortunately, the patient deteriorated and eventually succumbed to the illness before the diagnosis could be made. CONCLUSION: The case exemplifies the potential of venous sinus thrombosis to manifest as a spot sign, thereby emphasizing the need for a broader differential diagnosis. The rarity of venous spot signs may be attributed to patient-specific venous anatomy and poor collateralization in the occluded sinus territory.

Exploring Anatomical Variations of Abdominal Arteries Through Computed Tomography: Classification, Prevalence and Implications.

BACKGROUND AND AIMS: Variations in the branches of the abdominal aorta are relatively prevalent and can impact certain surgeries. The accurate identification and differentiation of these variations pre- and intraoperatively are crucial to avoid negative clinical sequelae. This study aimed to investigate the prevalence of variations in some branches of the abdominal aorta and to identify the most frequent variants as well as any rare variants not previously classified in the existing classification systems. The study's findings may help improve the understanding and management of these variations. MATERIALS AND METHODS: This retrospective study was conducted at the Department of Radiology at An-Najah National University Hospital (NNUH) and included 550 abdominal computed tomography (CT) angiographic scans for patients (51.5% males, 48.5% females) performed between January 2017 and January 2023. RESULTS: Variations were most common in the hepatic arteries (34.7%), followed by the renal arteries (31.3%). Variations in the celiac trunk were the least frequent (9.8%). The gastro-splenic trunk (type V) was the most common celiac trunk variant. The most common hepatic artery variant was the replacement of the right hepatic artery (type III). Accessory renal arteries were more frequent on the left side and among males (P = 0.01). The celiac trunk variations had a significant association with the hepatic artery variations (P = 0.001) and the renal artery variations (P = 0.011), respectively. CONCLUSION: There is a high prevalence of anatomical variations in the described vessels, and it matches the results in the reported literature. Our findings also suggest the possible coexistence of variants. We have also encountered rare variants, especially in the hepatic arterial system. Some of the hepatic arterial system variants are not included in the older classification systems, calling for an extension of the old systems (Michel's and Hiatt classification systems) or replacement with the newer (CRL or EX-CRL classification systems) to account for rare variants not previously classified. Radiologists and surgeons should be proficient in identifying and differentiating these variations to take precautions and actions for each variant individually.

Endovascular treatment for anterior inferior cerebellar artery-posterior inferior cerebellar artery (AICA-PICA) common trunk variant aneurysms: Technical note and literature review.

The Anterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery (AICA-PICA) common trunk is a rare variant of cerebral posterior circulation in which a single vessel originating from either the basilar or vertebral arteries supplies both cerebellum and brainstem territories. We present the first case of an unruptured right AICA-PICA aneurysm treated with flow diversion using a Shield-enhanced pipeline endovascular device (PED, VANTAGE Embolization Device with Shield Technology, Medtronic, Canada). We expand on this anatomic variant and review the relevant literature. A 39-year-old man presented to our treatment center with vertigo and right hypoacusis. The initial head CT/CTA was negative, but a 4-month follow-up MRI revealed a 9 mm fusiform dissecting aneurysm of the right AICA. The patient underwent a repeat head CTA and cerebral angiogram, which demonstrated the presence of an aneurysm on the proximal portion of an AICA-PICA anatomical variant. This was treated with an endovascular approach that included flow diversion via a PED equipped with Shield Technology. The patient's post-procedure period was uneventful, and he was discharged home after two days with an intact neurological status. The patient is still asymptomatic after a 7-month follow-up, with MR angiogram evidence of stable aneurysm obliteration and no ischemic lesions. Aneurysms of the AICA-PICA common trunk variants have a high morbidity risk due to the importance and extent of the territory vascularized by a single vessel. Endovascular treatment with flow diversion proved to be both safe and effective in obliterating unruptured cases.

Bell's palsy misdiagnosis: characteristics of occult tumors causing facial paralysis.

OBJECTIVE: The aim of this study was to report the incidence and clinical course of a series of patients who were misdiagnosed with Bell's palsy and were eventually proven to have occult neoplasms. METHODS: Two hundred forty patients with unilateral facial paralysis who were assessed at the facial nerve reanimation clinic, Victoria Hospital, London Health Science Centre, from 2008 through 2017 were reviewed. Persistent paralysis without recovery was the presenting complaint. RESULTS: Nine patients (3.8%) who were proven to have occult neoplasms initially presented with a diagnosis of Bell's palsy. The mean diagnostic delay was 43.5 months. Four patients were proven to have skin cancers, 3 patients had parotid cancers, and 2 patients had facial nerve schwannomas as a final diagnosis. Initial magnetic resonance imaging (MRI) was performed in all 9 patients and 8 underwent a follow-up MRI. An occult tumor was identified upon review of the original MRI in one patient and at follow-up MRI in 8 patients. The mean time interval between the initial and follow-up imaging was 30.8 months. The disease status at most recent follow-up were no evidence of disease in 2 patients (22%) and alive with disease in 7 patients (78%). An irreversible, progressive pattern of facial paralysis combined with pain, multiple cranial neuropathies or history of skin cancer were predictable risk factors for occult tumors. Seven out of the 9 patients (77.8%) underwent at least one type of facial reanimation surgery, and the final subjective results by the surgeon were available for 5 patients. Three out of the 5 (60%) patients who were available for final subjective analysis were reported as Grade III according to the modified House-Brackmann scale. CONCLUSION: Occult facial nerve neoplasm should be suspected in patients with progressive and irreversible facial paralysis but the diagnosis may only become evident with follow-up imaging. Facial reanimation surgery is a satisfactory option for these patients.

Ruptured intracranial infectious aneurysms: Single Canadian center experience.

Background: Ruptured intracranial infected aneurysms (IIAs) are relatively rare, but they portend high mortality. To the best of our knowledge, there is no Canadian case series on IIA, as well there is a relative paucity of international published experiences. Our purpose is to share the experience of a single Canadian tertiary center in managing ruptured IIA and to conduct a systematic review. Methods: We did a retrospective case review series of adult patients with ruptured IIA treated at our institution. Second, we conducted a systematic review of the literature on ruptured IIA between 2011 and 2021 inclusive. Results: At our institution, of a total eight cases with ruptured IIA, four were treated endovascularly and two by surgical bypass. For the systematic review, we included nine noncomparative studies with a total of 509 patients (318 males) and at least 437 ruptured IIA aneurysms. Favorable outcome was specified for 63.3% of patients (n = 57). Regarding ruptured IIA, favorable clinical outcome was described in 59.3% (n = 16). Conclusion: This study highlights a single Canadian tertiary center experience in the management of IIA and compares it to the global trends of the past 10 years in a systematic review.

A Protocol for Carotid Artery Stenting in COVID Times. A Single Canadian Centre Experience.

OBJECTIVES: The COVID-19 pandemic has resulted in huge disruption to healthcare delivery worldwide. There is a need to balance the urgent needs of the neurovascular patient population with the desire to preserve critical inpatient hospital capacity. It is incumbent on neurointerventionalists to advocate for their patients to minimise future disability. Patients still require semiurgent carotid revascularisation after ischaemic embolic events. We present a review of a novel protocol for expediting patient flow through the carotid stenting process, in accordance with government directives to minimise nonessential inpatient admissions, ensure its efficacy, and evaluate its safety. We also evaluate the literature regarding complications with attention to the timing of these related to the procedure. METHODS: A retrospective review of 45 consecutive carotid stenting cases performed at London Health Sciences Centre between March 2020 and March 2021 for symptomatic extracranial internal carotid artery stenosis utilising a default same-day discharge policy was performed. Complications were plotted as a function of time. RESULTS: Twenty-four patients underwent carotid artery stenting with same-day discharge and 21 patients underwent stenting with an overnight inpatient stay. A single stent occlusion occurred 27 h post stenting. CONCLUSION: Simple modification of protocol for symptomatic carotid artery stenting during the COVID-19 outbreak with radial access as first approach appears to provide safe, efficacious care.