Lanzino, Giuseppe

Abstract BACKGROUND Increased body mass index (BMI) may be protective against cerebral ischemia in certain clinical contexts. OBJECTIVE To investigate whether increased BMI was associated with delayed cerebral ischemia (DCI) and subsequent infarction after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed the clinical course of patients presenting to our institution for management of aSAH. Patient were segregated according to BMI< or ≥29.4, a value determined by Classification and Regression Tree analysis. Predictors of DCI and delayed infarction were identified using stepwise multivariate logistic regression analysis. RESULTS There were 161 patients included for analysis. Average BMI within our patient cohort was 28.9, with 67 patients presenting with a BMI of ≥29.4 on admission. DCI occurred in 50 patients (31.1%) and was complicated by delayed infarction in 15 patients (9.3%). On stepwise multivariate analysis, BMI ≥ 29.4 was independently associated with reduced likelihood of DCI (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.18-0.92) and delayed infarction (OR 0.13, 95% CI 0.02-0.61; P = .008). Increasing maximum flow velocity on transcranial Doppler ultrasound was independently associated with increased odds of both DCI (Unit OR 1.19, 95% CI 1.09-1.30; P < .001) and delayed infarction (Unit OR 1.31, 95% CI 1.13-1.56; P < .001), while intracerebral hemorrhage was independently associated with increased odds of delayed infarction (OR 6.99, 95% CI 1.82-30.25; P = .005). CONCLUSION We report an association between elevated BMI and reduced incidence of DCI and delayed infarction, suggesting a protective effect of increasing BMI on the risk of ischemic complications after aSAH.

BackgroundCarotid plaque imaging with MRI is becoming more commonplace, but practical challenges exist in performing plaque imaging with surface coils.PurposeTo compare the diagnostic performance of a carotid plaque MRI protocol using a standard neurovascular coil (Neurovascular Coil Protocol) to a higher‐resolution carotid plaque MRI using carotid surface coils (Surface Coil Protocol) in characterizing carotid plaque.Study TypeProspective study comparing two MR techniques in plaque characterization.PopulationThirty‐eight consecutive carotid artery disease patients.Field Strength/SequencePatients underwent 3T MRI using 1) a Neurovascular Coil Protocol including the following sequences: 3D‐FSE T1 pre/postcontrast and precontrast 3D IR‐FSPGR, and 2) a Surface Coil Protocol using standard multicontrast MRI sequences.AssessmentPlaque characteristics analyzed by two independent neuroradiologists included intraplaque hemorrhage (IPH), lipid‐rich necrotic‐core (LRNC), and thin/ruptured fibrous cap (TRFC).Statistical TestsDiagnostic performance of the Neurovascular Coil Protocol was compared to the Surface Coil Protocol reference standard using receiver‐operating curves.ResultsFor IPH, sensitivity, specificity, and area under the curve (AUC) of the Neurovascular Coil Protocol were 91.1% (95% confidence interval [CI] = 78.8–97.5%), 87.0% (95% CI = 66.4–97.2%), and 0.92, respectively. For LRNC without IPH sensitivity, specificity, and AUC were 73.3% (95% CI = 44.9–92.2%), 85.7% (95% CI = 67.3–96.0%), and 0.84, respectively. For TRFC, sensitivity, specificity, and AUC were 35.3% (95% CI = 14.2–61.7%), 97.6% (95% CI = 87.4–99.9%), and 0.66 respectively. Interobserver agreement for IPH, LRNC, and TRFC using the Neurovascular Coil Protocol were k = 0.87 (95% CI = 0.75–0.99), k = 0.54 (95% CI = 0.29–0.80), and k = 0.41 (95% CI = 0.08–0.74), respectively.Data ConclusionOur Neurovascular Coil Protocol has high sensitivity, specificity, and accuracy in identifying IPH and LRNC but is limited in assessment of TRFC.Level of Evidence: 1Technical Efficacy: Stage 2J. Magn. Reson. Imaging 2018;47:1264–1272.

Background. There is little published literature regarding the impact of age on outcomes amongst hospitalized HHT (hereditary hemorrhagic telangiectasia) patients. Methods. The Nationwide Inpatient Sample (NIS) was used to obtain data on all hospital discharges occurring in HHT patients from 2000 to 2012. The association between admission age and HHT-related complications and outcomes were studied. Results. 10293 hospitalizations in HHT patients from 2000 to 2012 were included. Patients > 50 accounted for 77% of all admissions with 30% of admissions occurring in the 51–65 age group. Bleeding related complications were the most frequent (62.7%, n=6455 hospitalizations), followed by cardiovascular (41%, n=4216), neurological (12.4%, n=1276), and hepatobiliary (6.4%, n=660) complications. Patients older than 50 accounted for 83% of bleeding events, 90% of cardiovascular events, 58% of neurologic events, and 81% of hepatobiliary events. The vast majority (83%) of medical and surgical procedures were performed in those older than 50 years of age. Older patients also experienced higher rates of death. Conclusion. Aging has significant adverse impacts on rates of hospitalization, complications, and outcomes amongst HHT patients in the United States. Except for neurologic complications, the vast majority of this disease burden is borne by patients older than 50 years.

Abstract BACKGROUND Neck remnants are not uncommon after endovascular treatment of cerebral aneurysms. Critics of endovascular treatments for cerebral aneurysms cite neck remnants as evidence in favor of microsurgical clipping. However, studies have failed to evaluate the true clinical significance of aneurysm neck remnants following endovascular therapies. OBJECTIVE To assess the clinical significance of residual aneurysm necks and to determine the rate of subsequent rupture following coiling or stent-assisted coiling of cerebral aneurysms. METHODS We retrospectively reviewed the records of 1292 aneurysm cases that underwent endovascular treatment at 4 institutions. Aneurysms treated by primary coiling or stent-assisted coiling were included in the study; those treated by flow diversion were excluded Aneurysms with residual filling (i.e., Raymond–Roy Occlusion Classification II, neck remnant; or III, residual aneurysm filling) were assessed for their risk of subsequent rupture. RESULTS A total of 626 aneurysms were identified as having residual filling immediately posttreatment. Of these, 13 aneurysms (2.1%) ruptured during the follow-up period (mean 7.3 mo; range 1-84 mo). Eleven of the 13 (84.6%) were ruptured at presentation. Rupture at presentation, the size of the aneurysm, and the increasing age of the patient were predictive of posttreatment rupture. CONCLUSION We found that unruptured aneurysms with residual necks following endovascular treatment posed a very low risk of rupture (0.6%). However, patients presenting with ruptured aneurysms had a higher risk of rerupture from a neck remnant (3.4%). These results highlight the importance of achieving complete angiographic occlusion of ruptured aneurysms.

Background and purpose Spinal arterial aneurysms are a rare cause of spinal subarachnoid hemorrhage (SAH). We performed a retrospective review of spinal arterial aneurysms not associated with spinal arteriovenus shunts from three institutions in order to better understand the clinical and imaging characteristics of these lesions. Materials and methods We performed a retrospective review of spinal arterial aneurysms managed at three North American institutions. For each patient, the following information was collected: demographic data, clinical presentation, comorbidities, imaging findings, and neurological status at the last follow-up. Treatment strategies and outcomes were reported. Results 11 patients were included; 7 were women and median age was 60 years. The most common presentation was sudden back pain (81.8%). We found 3 aneurysms on the radiculomedullary artery and 8 along the radiculopial arteries. Of the 3 aneurysms on the radiculomedullary artery, 1 was treated conservatively, 1 was treated with coiling of the aneurysm and sacrifice of the radiculomedullary artery, and 1 was treated with surgical trapping. The 8 aneurysms on the radiculopial artery were treated endovascularly in 4 cases, surgically in 1 case, and conservatively in 3 cases. One surgically treated patient had a spinal subdural hematoma. There were no other complications. Mean clinical follow-up time was 20 months, and 87.5% of patients were functionally independent. Conclusions Spinal arterial aneurysms are lesions which commonly present with sudden back pain and spinal SAH. Conservative, surgical, and endovascular treatment options are safe and effective. Long term outcomes in these patients are generally good.