Lanzino, Giuseppe

OBJECTIVE Traditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device. METHODS This study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. RESULTS A total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A 1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2. CONCLUSIONS PulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist’s armamentarium, especially with regard to its off-label use.

Numerous recent technological advances offer the potential to substantially enhance the MRI evaluation of moyamoya disease (MMD). These include high-resolution volumetric imaging, high-resolution vessel wall characterization, improved cerebral angiographic and perfusion techniques, high-field imaging, fast scanning methods, and artificial intelligence. This review discusses the current state-of-the-art MRI applications in these realms, emphasizing key imaging findings, clinical utility, and areas that will benefit from further investigation. Although these techniques may apply to imaging of a wide array of neurovascular or other neurological conditions, consideration of their application to MMD is useful given the comprehensive multidimensional MRI assessment used to evaluate MMD. These MRI techniques span from basic cross-sectional to advanced functional sequences, both qualitative and quantitative. The aim of this review was to provide a comprehensive summary and analysis of current key relevant literature of advanced MRI techniques for the evaluation of MMD with image-rich case examples. These imaging methods can aid clinical characterization, help direct treatment, assist in the evaluation of treatment response, and potentially improve the understanding of the pathophysiology of MMD.

Background and purpose Cervical internal carotid artery (ICA) tortuosity is thought to impede distal catheterization during attempted mechanical thrombectomy in patients with acute ischemic stroke. This study sought to assess the morphologic characteristics of ICAs and the effects of tortuosity on thrombectomy attempts. Methods A retrospective review was completed of neck CTAs of patients with acute ischemic stroke due to a large vessel occlusion that underwent attempted endovascular recanalization. Significant tortuosity of ICAs was defined as the presence of kink(s) (acute (<90°) angulation), loop(s) (C- or S-shaped curvature with 2+ areas of acute (<90°) angulation), or coil(s) (full 360° turn arterial bend). Findings were statistically compared to procedure time, successful recanalization rate, patient demographics, and co-morbidities. Results Of 120 included patients, 47 (39.2%) had some form of tortuosity of one or both ICAs. Twenty-eight patients (23.3%) had a kink of one or both ICAs; this was followed in frequency by loops (n = 20; 16.7%) and coils (n = 8; 6.7%). Kinks were associated with lower rates of successful recanalization (p = 0.02). The presence of any tortuosity (kinks, loops, or coils) was not associated with number of passes during thrombectomy (p = 0.88), successful recanalization (p = 0.11), or total procedure time (p = 0.22). No association was noted between the presence of tortuosity and age (p = 0.96) or prior or current tobacco use (p = 0.75 and p = 0.69, respectively). Conclusion Among patients referred for urgent revascularization for large vessel occlusion, approximately 40% exhibit some tortuosity. Kinks may portend lower likelihood of recanalization success, although tortuosity as a whole seems to have little effect on endovascular thrombectomy.

Background Carotid-cavernous fistulas (CCFs) are commonly misdiagnosed on computed tomography angiography (CTA). Purpose This study sought to identify the most sensitive and specific imaging features of CCFs on CTA. Material and Methods A retrospective review identified 18 consecutive patients suspected of having a CCF on CTA and subsequently underwent digital subtraction angiography (DSA). Two blinded reviewers assessed multiple findings on CTA: cavernous sinus asymmetry/enlargement; arterial-phase contrast in the cavernous sinus; proptosis; pre- or post-septal orbital edema; and dilated regional vasculature. Each was graded as positive, possible, and negative; “possible” was counted as positive. A third blinded reviewer served as a tiebreaker. Results Of 18 patients, nine were true-positive and nine were false-positive. Superior ophthalmic vein early enhancement and dilatation had 100.0% sensitivity (95% confidence interval [CI] 40.0–100.0) and 77.8% specificity (95% CI 44.4–100.0); arterial-phase contrast in the cavernous sinus had 88.9% sensitivity (95% CI 44.4–100.0) and 66.7% specificity (95% CI 18.5–90.1); peri-orbital edema had 88.9% sensitivity (95% CI 35.5–100.0) and 77.8% specificity (95% CI 22.2–100.0). The most specific markers of CCF were superior petrosal sinus and inferior ophthalmic vein dilatation/enhancement (100.0%, 95% CI 88.8–100.0 and 88.9%, 95% CI 44.4–100.0, respectively); the specificity of asymmetric cavernous enlargement was 44.4% (95% CI 11.1–77.7). Conclusions Among patients in whom a CCF is suspected on CTA, superior ophthalmic vein dilatation/enhancement and arterial-phase contrast within the cavernous sinus are the most sensitive findings. Asymmetric cavernous sinus enlargement has poor specificity and may result in false-positive diagnoses of CCFs. False positive cases were less likely to have an optimally timed contrast bolus.

Spinal cord intramedullary arteriovenous malformations (AVMs) have classically been considered congenital lesions that are present from birth. The reason for this dogmatic principal is the fact that a vast majority of these lesions present in pediatric and young adult patients. Interestingly, while many authors have demonstrated the development of de novo nidus-type brain AVMs, there have been no reported cases of a de novo intramedullary or perimedullary AVM of the spine. In this paper the authors describe what they believe to be the first reported case of a de novo AVM of the spinal cord in a young patient who underwent serial imaging from birth for evaluation of a syrinx. Potential pathophysiological mechanisms for the development of de novo vascular malformations of the spinal cord are discussed.

OBJECTIVEDelayed cerebral ischemia (DCI) and aneurysm rebleeding contribute to morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH); however, the relationship between their impacts on overall functional outcome is incompletely understood.METHODSThe authors conducted a cohort study of all aSAH during the study period from 2001 to 2016. Primary end points were overall functional outcome and ischemic aSAH sequelae, defined as delayed cerebral ischemia (DCI), DCI with infarction, symptomatic vasospasm (SV), and global cerebral edema (GCE). Outcomes were compared between the rebleed and nonrebleed cohorts overall and after propensity-score matching (PSM) for risk factors and treatment modality. Univariate and multivariate ordered logistic regression analyses for functional outcomes were performed in the PSM cohort to identify predictors of poor outcome.RESULTSFour hundred fifty-five aSAH cases admitted within 24 hours of aneurysm rupture were included, of which 411 (90%) experienced initial aneurysm ruptures only, while 44 (10%) had clinically confirmed rebleeding. In the overall cohort, rebleeding was associated with significantly worse functional outcome, longer intensive care unit length of stay (LOS), and GCE (all p < 0.01); treatment modality, overall LOS, DCI, DCI with infarction, and SV were nonsignificant. In the PSM analysis of 43 matched rebleed and 43 matched nonrebleed cases, only poor functional outcome and GCE remained significantly associated with rebleeding (p < 0.01 and p = 0.02, respectively). Multivariate regression identified that both rebleeding (HR 21.5, p < 0.01) and DCI (HR 10.1, p = 0.01) independently predicted poor functional outcome.CONCLUSIONSRebleeding and DCI after aSAH are highly morbid and potentially deadly events after aSAH, which appear to have independent negative impacts on overall functional outcome. Early rebleeding did not significantly affect the risk of delayed ischemic complications.

Background and Purpose— Several angiographic factors of dural arteriovenous fistulas (dAVFs) are associated with aggressive presentation and poor natural history. We examined the association of magnetic resonance imaging T2-weighted-Fluid-Attenuated Inversion Recovery (T2/FLAIR) hyperintensity with aggressive presentation. Methods— A cohort of dAVF patients from 2 centers was retrospectively examined. T2/FLAIR hyperintensity was determined by blinded, de-identified review and compared with angiographic grade and presenting symptoms. Results— T2/FLAIR hyperintensity was only identified in dAVF patients with cortical venous drainage (CVD). Among patients with CVD, those with T2/FLAIR hyperintensity were more likely to present with aggressive symptoms (20/23, 87.0%) than those without (6/21, 28.5%), P <0.001. All cured dAVFs with symptom resolution and available post-treatment imaging had resolution of T2/FLAIR hyperintensity. Conclusions— T2/FLAIR hyperintensity strongly correlates with aggressive presentation and CVD in dAVF patients, and may identify a subset that would benefit from early treatment.