Rajah, Gary

OBJECTIVE Steno-occlusive diseases of the cerebral vasculature have been associated with cognitive decline. The authors performed a systematic review of the existing literature on intracranial steno-occlusive disease, including intracranial atherosclerosis and moyamoya disease (MMD), to determine the extent and quality of evidence for the effect of revascularization on cognitive performance. METHODS A systematic search of PubMed/MEDLINE, the Thomson Reuters Web of Science Core Collection, and the KCI Korean Journal Database was performed to identify randomized controlled trials (RCTs) in the English-language literature and observational studies that compared cognitive outcomes before and after revascularization in patients with steno-occlusive disease of the intracranial vasculature, from which data were extracted and analyzed. RESULTS Nine papers were included, consisting of 2 RCTs and 7 observational cohort studies. Results from 2 randomized trials including 142 patients with symptomatic intracranial atherosclerotic steno-occlusion found no additional benefit to revascularization when added to maximal medical therapy. The certainty in the results of these trials was limited by concerns for bias and indirectness. Results from 7 observational trials including 282 patients found some cognitive benefit for revascularization for symptomatic atherosclerotic steno-occlusion and for steno-occlusion related to MMD in children. The certainty of these conclusions was low to very low, due to both inherent limitations in observational studies for inferring causality and concerns for added risk of bias and indirectness in some studies. CONCLUSIONS The effects of revascularization on cognitive performance in intracranial steno-occlusive disease remain uncertain due to limitations in existing studies. More well-designed randomized trials and observational studies are needed to determine if revascularization can arrest or reverse cognitive decline in these patients.

Neuromodulation and deep brain stimulation (DBS) have been increasingly used in many neurological ailments, including essential tremor, Parkinson’s disease, epilepsy, and more. Yet for many patients and practitioners the desire to utilize these therapies is met with caution, given the need for craniotomy, lead insertion through brain parenchyma, and, at many times, bilateral invasive procedures. Currently endovascular therapy is a standard of care for emergency thrombectomy, aneurysm treatment, and other vascular malformation/occlusive disease of the cerebrum. Endovascular techniques and delivery catheters have advanced greatly in both their ability to safely reach remote brain locations and deliver devices. In this review the authors discuss minimally invasive endovascular delivery of devices and neural stimulating and recording from cortical and DBS targets via the neurovascular network.

Abstract We present a case of a traumatic skull base internal carotid artery (ICA) pseudoaneurysm treated with endovascular flow diversion stenting. The patient was a 27-year-old male who was involved in a motorcycle accident suffering multiple traumatic injuries including a large skull base fracture that extended through the carotid canal. Computed tomography angiography revealed a 2-cm right ICA pseudoaneurysm. Once the patient was stable, a digital subtraction angiography demonstrated enlargement of the pseudoaneurysm. After his other injuries were addressed by trauma and orthopedic surgery, at day 9 after his initial injury, the patient was loaded with aspirin and clopidrogel in preparation for stent reconstruction of his ICA injury. Under conscious sedation and systemic heparinization, the patient underwent endovascular reconstruction of the large pseudoaneurysm using telescoping flow diversion stents. Immediate intra-aneurysm flow stasis was observed. No procedure-related complications occurred. The patient did well and at last follow-up remained neurologically intact.