Endovascular therapy for acute ischemic stroke after cardiac surgery: Why not?

There are few publications regarding the use of endovascular therapy (EVT) for the treatment of acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) after cardiac surgery. In the manuscript entitled "Endovascular Thrombectomy for Large Vessel Occlusion Acute Ischemic Stroke after Cardiac Surgery," Gupta et al. report their experience with EVT for AIS after cardiac surgery.

Evaluating the Routine Use of Head Computed Tomography Angiography in Blunt Cerebrovascular Trauma.

BACKGROUND: The aim of this study was to evaluate a protocol change that mandated routine incorporation of head computed tomography angiography (CTA) for the work-up of suspected blunt cerebrovascular injury (BCVI) at an academic Level I trauma center. METHODS: The BCVI screening guidelines at our institution changed in 2018 to include the addition of a head CTA for all patients receiving a neck CTA as part of our BCVI screening guidelines. We performed a retrospective chart review of patients between 2018 and 2019 who were 18 years or older and met screening criteria for BCVI based on our institutional guidelines. The head CTAs of this cohort were assessed for findings that could potentially alter the course of the patients' treatment. RESULTS: A total of 319 patients fit this criterion and had a head CTA as part of their trauma workup. Findings that could potentially alter a patient's clinical course were identified in 6.6% (n = 21) of the head CTA's. These included decreased arterial perfusion (n = 9), active bleeds (n = 6), vessel occlusions (n = 1), aneurysms (n = 1), and vasospasms (n = 2). Of these 21 patients, 8 had clinically significant findings that affected their course of management (2.5% of total sample). They also had a higher mortality rate and ISS compared to the rest of the cohort. CONCLUSIONS: In patients with clinically suspected BCVI, the addition of head CTA to the existing BCVI screening guideline identified clinically significant vascular abnormalities that affected management in 2.5% of cases.

Chronic inferior vena cava filter thrombosis presenting with low back pain and radiculopathy: Treatment with thrombolysis, filter removal, and stenting.

BACKGROUND: Epidural venous congestion secondary to inferior vena cava (IVC) stenosis is a well-documented cause of low back pain and radiculopathy secondary to compressive effects from the epidural veins, decreased tissue perfusion, and resultant ischemia. METHODS: Single patient case report. CASE DESCRIPTION: We report a unique case of a 62-year-old male with low back pain secondary to IVC stenosis from a chronically occluded IVC filter. The patient's pain resolved with endovascular removal of the occluded filter and recanalization of the IVC. CONCLUSION: We demonstrated that by treating the underlying cause of secondary epidural venous engorgement (occluded IVC filter in this case), the patient experienced resolution of back pain and radiculopathy.

Analysis of Demographic and Educational Backgrounds of Interventional Neuroradiology Fellowship Program Director Workforce in North America.

PURPOSE: To analyse the demographics, academic background, and scholarly activity of Interventional Neuroradiology (INR)/Endovascular Surgical Neuroradiology (ESN) program directors (PDs) in the United States (US) and Canada. METHODS: A list of all INR/ESN fellowships was obtained from the Accreditation Council for Graduate Medical Education, the Committee on Advanced Subspecialty Training, maintained by Society of Neurological Surgeons, the NeuroInterventional Training list website maintained by the Society of NeuroInterventional Surgery, and the Neurosurgical Fellowship Training Program Directory website maintained by the American Association of Neurological Surgeons. Online search was performed to identify PDs for these programs. Publicly available sources used to gather information about each PD included the program websites, the HealthGrades and Doximity websites, and Elsevier's Scopus database. Demographic and educational data including age, gender, educational background, subspecialty, appointment age, interval between residency completion and appointment as PD, additional degrees, academic rank, prior leadership positions, and metrics of scholarly activity were recorded. One-way analysis of variance was used to determine differences between the means of different groups. RESULTS: A total of 78 PDs from 72 programs were included, of which 72 (92.3%) were male with the mean age of 49.59 years (SD 7.25). Specialty division of PDs was neurosurgery (40, 51.3%), radiology (26, 33.3%), and neurology (10, 12.8%), whereas 2 PDs were dual board-certified in neurology and radiology. Twenty-five (32.1%) PDs attended an international medical school. All PDs received an MD degree or foreign equivalent, with no PD holding a DO degree. Eleven PDs received a PhD degree and 16 PDs received fellowship from a professional medical society. The mean ± SD publications, citations, and h-indexes of PDs were 111.32 ± 121.18, 2985.0 ± 1459.0 and 22.27 ± 15.45, respectively. There was no statistical difference in scholarly activity among PDs when stratified on the basis of specialty, gender, and US region. CONCLUSION: INR/ESN PDs are predominantly male, with a majority from neurosurgery background, and thirty percent having graduated from international medical schools.

Critical Evaluation of Interventional Neuroradiology Fellowship Program Websites in North America.

OBJECTIVE: To investigate the accessibility and content of interventional neuroradiology (INR) fellowship program websites in North America. METHODS: We obtained a list of INR/endovascular surgical neuroradiology (ESN) fellowship programs from the Accreditation Council for Graduate Medical Education, the Committee on Advanced Subspecialty Training, the Society of NeuroInterventional Surgery, and the Neurosurgical Fellowship Training Program Directory websites. Individual program websites were evaluated for 27 different fellow recruitment and education criteria. U.S. programs were grouped based on census region and national ranking, and differences between these groups with regard to fellow recruitment and education characteristics were analyzed using nonparametric statistics. RESULTS: A total of 79 INR/ESN fellowship websites were evaluated for presence of fellow recruitment and education features. Approximately one third of all features pertinent to recruitment (32.11%) and approximately 1 in 5 features regarding education (19.11%) were described in these websites. Program description (69.6%), program coordinator/administrator contact e-mail (59.5%), program director's name (59.5%), program eligibility requirements (51.9%), research opportunities (40.5%), and faculty listing (39.2%) were among the most frequently described features, whereas details about parking (1.3%), interview day itinerary (1.3%), meal allowance (2.5%), retirement and benefits (3.8%), and call schedule (5.1%) were the least frequently described features. There was no significant difference between surveyed features and programs when stratified by U.S. census region, neurosurgery/neurology hospital rankings, or accreditation status. CONCLUSIONS: INR/ESN fellowship website content is variable across North America and there is room for improvement to develop and enhance comprehensiveness of program website content.

Use of Embolic Protection Devices in Peripheral Interventions.

The use of embolic protection devices (EPDs) when treating coronary saphenous vein bypass grafts, performing carotid arterial stenting and treating acute coronary syndromes is well accepted. We will review currently available devices and approaches to reduce distal embolisation, first discussing their uses in carotid interventions and then in vertebral and peripheral vascular interventions.

Interobserver Agreement on Arteriovenous Malformation Diffuseness Using Digital Subtraction Angiography.

BACKGROUND: Arteriovenous malformation (AVM) diffuseness has been shown to be prognostic of treatment outcomes. We assessed interobserver agreement of AVM diffuseness among physicians of different specialty and training backgrounds using digital subtraction angiography (DSA). METHODS: All research protocols were approved by the institutional review board for this retrospective chart review. In a single-blinded setting, 2 attending neurosurgeons, 1 attending interventional neuroradiologist, and 1 senior neurosurgical resident rated 80 DSA views of 36 AVMs as either compact or diffuse. Individual interobserver agreement and subgroup agreement were analyzed using κ agreement and intraclass correlation coefficient. RESULTS: Disagreement regarding AVM diffuseness occurred in 43.8% of all DSA views (n = 80). Interobserver κ agreement on AVM diffuseness using DSA views among 4 physicians ranged from fair (κ = 0.40 [95% confidence interval (CI) = 0.22-0.58]) to substantial (κ = 0.65 [95% CI = 0.48-0.81]), whereas total intraclass correlation coefficient was 0.81 (95% CI = 0.73-0.87). For the 36 AVMs, κ agreement ranged from fair (κ = 0.36 [95% CI = 0.13-0.60]) to moderate (κ = 0.57 [95% CI = 0.35-0.79]), whereas intraclass correlation coefficient among all 4 physicians was 0.68 (95% CI = 0.47-0.82). Moderate agreement on AVM diffuseness (n = 80) was found between attending and resident assessments (κ = 0.57 [95% CI = 0.39-0.75]) and between neurosurgeon and interventional neuroradiologist assessments (κ = 0.55 [95% CI = 0.37-0.73]). CONCLUSIONS: Agreement of individual physicians on AVM diffuseness varies from fair to substantial. Objective and three-dimensional measures of AVM diffuseness should be developed for consistent clinical application.

VENOUS SAMPLING FOR CUSHING DISEASE: COMPARISON OF INTERNAL JUGULAR VEIN AND INFERIOR PETROSAL SINUS SAMPLING.

OBJECTIVE: Because magnetic resonance imaging (MRI) fails to detect many adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas, inferior petrosal sinus sampling (IPSS) is considered the gold standard to differentiate Cushing disease (CD) from ectopic ACTH secretion syndrome (EAS). Some authors have suggested internal jugular vein sampling (IJVS) as an alternative to IPSS. METHODS: We simultaneously compared IJVS to IPSS in 30 consecutive patients referred for ACTH-dependent Cushing syndrome and equivocal MRI exams. Five sites were simultaneously sampled in each patient (right and left IPS, right and left IJV, and femoral vein) before and after the administration of corticotrophin-releasing hormone or desmopressin. The test was considered consistent with CD when the IPS to peripheral ratio was >2 at baseline or >3 after stimulus and the IJV to peripheral ratio was >1.7 at baseline or >2 after stimulus. RESULTS: In 27 of 30 patients, IPSS results were consistent with a central source of ACTH. Two of the other 3 patients had EAS (one lung carcinoid and one occult), and 1 patient had pathology-proven CD. The sensitivity of IPSS was 96.4%. Only 64.2% of these patients had results meeting criteria for a central source of ACTH by IJVS criteria. Twenty patients with centralizing IPPS have undergone pituitary surgery. Of these, the central origin of excessive ACTH was confirmed with certainty in 16 patients. Among these 16 patients, the IPSS sensitivity was 93.8%, whereas 5 patients had false-negative IJVS (68.7% sensitivity). CONCLUSION: These results do not support the routine use of IJVS in establishing if the pituitary is the source of excessive ACTH. ABBREVIATIONS: ACTH = adrenocorticotropic hormone CD = Cushing disease CRH = corticotrophin-releasing hormone CS = Cushing syndrome DDAVP = desmopressin EAS = ectopic ACTH secretion IJVS = internal jugular vein sampling IPSS = inferior petrosal sinus sampling JVS = jugular venous sampling MRI = magnetic resonance imaging.

Security Issues for Mobile Medical Imaging: A Primer.

The end-user of mobile device apps in the practice of clinical radiology should be aware of security measures that prevent unauthorized use of the device, including passcode policies, methods for dealing with failed login attempts, network manager-controllable passcode enforcement, and passcode enforcement for the protection of the mobile device itself. Protection of patient data must be in place that complies with the Health Insurance Portability and Accountability Act and U.S. Federal Information Processing Standards. Device security measures for data protection include methods for locally stored data encryption, hardware encryption, and the ability to locally and remotely clear data from the device. As these devices transfer information over both local wireless networks and public cell phone networks, wireless network security protocols, including wired equivalent privacy and Wi-Fi protected access, are important components in the chain of security. Specific virtual private network protocols, Secure Sockets Layer and related protocols (especially in the setting of hypertext transfer protocols), native apps, virtual desktops, and nonmedical commercial off-the-shelf apps require consideration in the transmission of medical data over both private and public networks. Enterprise security and management of both personal and enterprise mobile devices are discussed. Finally, specific standards for hardware and software platform security, including prevention of hardware tampering, protection from malicious software, and application authentication methods, are vital components in establishing a secure platform for the use of mobile devices in the medical field.

Serial Imaging Surveillance for Patients With a History of Intracranial Aneurysm: Risk of De Novo Aneurysm Formation.

BACKGROUND: Although rare, de novo intracranial aneurysms (DNIAs) may develop in patients with a history of intracranial aneurysms (IAs). OBJECTIVE: To evaluate the benefit of routine radiographic screening for DNIAs. METHODS: Data for 2153 patients with IAs were retrospectively analyzed. A total of 185 patients underwent screening for DNIAs at frequent intervals. RESULTS: Overall, DNIAs were detected in 26 patients (1.2%). Of the 185 patients with surveillance, DNIAs developed in 9 (4.9%). The risk of DNIA detection was 1.14% per person-year of follow-up (95% confidence interval: 0.6%-2.2%). Patients with imaging follow-up had a significantly higher rate of DNIA detection compared with patients without regular imaging surveillance (4.9% vs 0.86%; P < .001), but surveillance was associated with smaller lesions (with surveillance: 3.8 ± 1.8 mm, without: 7.0 ± 4.4 mm, mean ± standard deviation; P = .026). A unimodal distribution of time to detection was found in those with surveillance, with a peak between 0 and 2 years. There was a trend toward an association of cigarette smoking and DNIA detection within 10 years (P = .06); 6 of the 26 patients (23.1%) with DNIAs had a history of cigarette smoking, with all 6 patients continuing to smoke up to the detection of the DNIAs, which were detected in 2.5 ± 1.8 years. CONCLUSION: The low 1.14% per-person year risk of DNIA detection and small DNIA size at detection cannot justify routine screening for DNIAs in all patients with a personal history of IAs. If imaging follow-up is considered for selected patients, early screening will likely yield the most benefit in patients who continue to smoke cigarettes.

Venous sinus stenting is a valuable treatment for fulminant idiopathic intracranial hypertension.

Over the past 10 years, transverse sinus stenting has grown in popularity as a treatment for idiopathic intracranial hypertension. Although promising results have been demonstrated in several reported series, the vast majority of patients in these series have been treated on an elective basis rather than in the setting of fulminant disease with acute visual deterioration. We identified four patients who presented with severe acute vision loss between 2008 and 2012 who were treated with urgent transverse sinus stenting with temporary cerebrospinal fluid (CSF) diversion with lumbar puncture or lumbar drain as a bridge to therapy. All patients presented with headache, and this was stable or had improved at last follow-up. Three patients had improvement in some or all visual parameters following stenting, whereas one patient who presented with severe acute vision loss and optic disc pallor progressed to blindness despite successful stenting. We hypothesize that she presented too late in the course of the disease for improvement to occur. Although the management of fulminant idiopathic intracranial hypertension remains challenging, we believe that transverse sinus stenting, in conjunction with temporary CSF diversion, represents a viable treatment option in the acute and appropriate setting.

Acute, subacute, and long-term evaluation of a novel endovascular occlusion system in a large animal model.

OBJECTIVES: Endovascular occlusion of blood vessels represents a key component of interventional therapy. While coils are most commonly used, vessel occlusion is generally not achieved immediately and may necessitate a large number of devices. It has been suggested that endovascular plugs may overcome these limitations; however, immediate and durable occlusion remains a challenge with plugs as well. This study evaluates a newly designed endovascular occlusion system (EOS) METHODS: The EOS combines a nitinol coil with an impermeable membranous cap made of expanded polytetrafluoroethylene. The coil offers sufficient radial force to expand the membrane and minimize post-deployment migration. Fifteen test devices were deployed in the iliac (external and internal) and femoral arteries of five miniature swine, while two commercially available devices (platinum coils and a vascular plug) were used as controls in one miniswine. Angiography was performed 1, 5, and 10 minutes after device implantation. Follow-up angiography was obtained either on day 29 or day 61, prior to devices harvesting for histological evaluation and biocompatibility assessment. RESULTS: No clinical complications were observed in the animals throughout the study course. All test devices were deployed as intended, and produced complete and immediate vessel-occlusion. No recanalization or acute migration was observed within 10 minutes of deployment, whereas five test devices had migrated between 5 and 15 mm at follow-up angiography. Complete and durable vessel-occlusion without any sign of recanalization was observed in all EOS devices during the follow-up period. CONCLUSION: The EOS is a safe and reliable device resulting in immediate and durable vessel occlusion in the peripheral arterial circulation. While no device migration was observed in the pelvic area, it was observed with five test and one control devices in the vicinity of highly mobile articulations, leading to the conclusion that occlusion devices should not be placed within hypermobile areas such as the hip joint.