Lanzino, Giuseppe

Abstract Perimedullary fistulae of the spinal cord are rare vascular lesions that can present with different clinical patterns: hemorrhage, progressive myelopathy due to arterial steal and/or venous congestion, or symptoms due to compression of neural structures by engorged vessels. Treatment consists of surgical excision, endovascular embolization, or a combination of the two. If complete obliteration of the nidus exposes the patient to undue risk of permanent neurological deficits, incomplete obliteration with reduction of the vascular supply is a reasonable compromise to improve clinical symptomatology. Partial devascularization may also alter the natural history by decreasing the risk of further growth and bleeding. In this video we illustrate the case of a patient with a perimedullary fistula of the conus treated with surgical disconnection of the main fistulous component. Partial devascularization resulted in resolution of MRI signal changes and symptoms with documented good clinical and radiological outcome and progressive regression of the residual nidus over six years of follow-up.

Summary Cardiac surgery has been shown to be associated with increased risk of acute ischemic stroke. This report presents a case of a successful mechanical embolectomy procedure to treat a patient for an acute ischemic stroke, which was caused by the cardiac embolization of a ‘foreign body’ containing debris following a redo sternotomy procedure for mitral valve replacement and tricuspid valve annuloplasty.

Background: There are concerns about use of certain medications in patients with cavernous malformations (CM) being deleterious such as antithrombotics. In addition, there are select medications such as statins, vitamin D, and NSAIDs which theoretically may have a positive effect on endothelial leakiness. We aimed to determine whether certain medications taken prior to the diagnosis of CM influenced the presentation to medical attention. Methods: We established a prospective cohort of patients with clinically diagnosed CM in 2015. Patients are interviewed at inception and clinical records reviewed. Specifically, several medications are recorded including the use of: antithrombotics, NSAIDs, estrogen, Vitamin E, Vitamin D, SSRI, statin, and multivitamin. Patients are followed prospectively. Data continues to be collected annually on outcome events (bleeding) and ongoing medication use. Results: These results are on the first 103 patients entered into the database. Sixty-four (62.1%) patients are male and the average age at diagnosis is 39.1 years. Sixty-three (61.1%) presented with symptoms and 40 (38.9%) were incidental findings at first diagnosis. Patients taking NSAIDs (p=0.0468), Vitamin D (p=0.035), and statins (p=0.0163) were more likely to present with an incidental CM compared to those who presented symptomatically (hemorrhage, seizure or focal neurologic deficit). There was no significant difference in symptomatic vs. asymptomatic presentation in patients taking estrogens, warfarin, clopidogrel, SSRI, or vitamin E prior to presentation. Conclusion: This data supports the theoretic role of vitamin D, NSAIDS, and statin use in stabilization of endothelial permeability. Ongoing data collection and prospective follow up will allow us to determine if ongoing use of these medications plays a role in reducing risk of future hemorrhage.

Background and purpose Thoracolumbar and sacral spinal epidural arteriovenous fistulas (SEDAVFs) are an increasingly recognized form of spinal vascular malformation. The purpose of this study was to perform a systematic review of the demographics, clinical presentation and treatment results of thoracolumbar SEDAVFs. Materials and methods Pubmed, Scopus and Web of Science databases were searched from January 2000 to January 2018 for articles on treatment of SEDAVFs. Pooled data of individual patients were analyzed for demographic and clinical features of SEDAVFs as well as treatment outcomes. Results There were 125 patients from 11 studies included. Mean age was 63.5 years. There was a male sex predilection (69.6%). Sensory symptoms including pain or numbness were the most frequently presenting symptoms. Fistula location was the lumbosacral spine in 79.2% and the thoracic spine in 20.8%. Involvement of intradural venous drainage was more common than extradural venous drainage only (89.6% vs 10.4%). Of the 123 treated patients, endovascular therapy was performed in 67.5% of patients, microsurgery in 23.6%, and combined treatment in 8.9%. The overall complete obliteration rate was 83.5% and did not differ between groups. Clinical symptoms improved in 70.7% of patients, were stable in 25%, and worsened in 1.7% with no difference between treatment modalities. Conclusions Thoracic and lumbosacral SEDAVFs often present with symptoms secondary to congestive myelopathy or compressive symptoms. Both endovascular and microsurgical treatments were associated with high obliteration rates and good clinical outcomes.

OBJECTIVEClinical trials forming the basis of current guidelines for the management of intracranial aneurysms have relied on patient-reported modified Rankin Scale (mRS) scores to assess functional outcome. The effect of patient demographics on perception of disability and, by extension, patient-reported mRS score, is not well understood.METHODSA consecutive series of patients with a previously treated or untreated unruptured intracranial aneurysm (UIA) prospectively underwent a structured interview with a trained nurse. At the conclusion of this interview, the patients were assigned an mRS score in accordance with their degree of disability. During the same visit, patients were also required to grade themselves on a paper sheet containing the mRS and corresponding information. Data on patient and aneurysm characteristics were also collected during the same visit. Agreement between patient- and nurse-reported mRS scores was assessed using Cohen’s kappa coefficient. The effect of patient demographics on the frequency of higher patient- than nurse-reported mRS scores was assessed using the Pearson’s chi-square and Fisher’s exact tests.RESULTSA total of 209 patients with a UIA were included in the study, 38 of whom (18.2%) had undergone previous treatment. The majority of patients were female (161/209, 77.0%), and the mean age of the cohort was 60.2 years (SD 13.7 years). Agreement between patient- and nurse-reported mRS scores occurred in 72.7% of cases (95% CI 66.3%–78.3%), with a kappa coefficient of 0.58 (95% CI 0.49–0.67). Patients younger than 75 years were more likely to report a higher mRS score than the nurse (19.4% vs 3.4%, p = 0.034). Among female patients, those without a college degree were more likely to report a higher mRS score than the nurse (22.5% vs 9.5%, p = 0.035).CONCLUSIONSThe results suggest that patient demographics may influence perception of disability. These findings should be considered when using patient-reported mRS scores to determine functional outcome.

Abstract While revascularization of the acutely or chronically occluded internal carotid artery has become commonplace with modern endovascular techniques, revascularization of an acutely occluded common carotid artery (CCA) is a controversial procedure with unique challenges. These challenges can be related to the lack of observable markers for identifying vessels during navigation or for identifying the exact location and extent of occlusion within the CCA, in addition to wide-ranging treatment risks. In this video, we illustrate the controversial revascularization of a 68-yr-old woman with an acute CCA occlusion who presented with fluctuating neurological symptoms. We believed treatment to be indicated by the lack of adequate collaterals on the intracranial CTA, and fluctuating symptoms in the absence of an intracranial major vessel occlusion, suggesting that the CCA occlusion was exerting important hemodynamic effects and at risk of causing a major stroke without revascularization, despite a low initial NIH stroke score. Though acute recanalization of patients with low NIH stroke score with stent-angioplasty is a controversial procedure, we believed it to be necessary in the case of our patient and believe it will likely be the focus of the next wave of large clinical trials dedicated to acute stroke.