Citations

Background The formation of dissecting pseudoaneurysms (dPSAs) is a common sequela of cervical artery dissection, which has been suggested to increase thrombotic risk in previous studies. This study reported clinical features and long‐term outcomes of cervical internal carotid (cICA) and vertebral artery (cVA) dPSAs. Methods We performed a retrospective chart review over a 10‐year period (January 2012–December 2021). Baseline demographics and clinical characteristics, medical and endovascular treatments, and long‐term outcomes were reported for cICA and cVA dPSA groups separately. Nonparametric tests were used to compare group differences. Results In our cohort, 120 (12%) of 999 cervical artery dissection patients had dPSA, with 85% occurring in the cICA and 15% in the cVA. Most dPSAs occurred spontaneously or in association with minor trauma. Compared with cICA dPSA, patients with cVA dPSA were younger (median age [range]=34.5 [24–70] versus 52 [30–77]; P <0.01), had a smaller dPSA size (median size [range]=4.5 mm [2–17] versus 8 mm [1.2–32]; P <0.01), and were more likely to reduce in size at follow‐up (median size change [range]=−2.8 mm [−17;0] versus 0 [−24;10.8]). Antithrombotic therapy was predominately aspirin monotherapy. No patients with cVA dPSA experienced recurrent strokes and only 3% of patients with cICA dPSA developed new/recurrent stroke in the territory of dPSA while on an antithrombotic regimen requiring endovascular intervention, and none of the dPSAs ruptured. A total of 98% of the patients had an excellent outcome (modified Rankin scale 0–2 at final follow‐up). Conclusion Most cICA and cVA dPSAs have a benign prognosis with medical therapy alone. Further prospective randomized clinical trials are needed to provide high quality evidence on the necessity of additional endovascular therapy at diagnosis in addition to medical therapy alone.

Abstract Background Carotid intraplaque hemorrhage (IPH) is considered a strong marker of histologically defined plaque vulnerability leading to cerebrovascular ischemic events. Cerebral microbleeds (CMBs) represent hemorrhage-prone small vessel disease and they are a common finding on brain MRI in patients with cerebrovascular disease. However, the potential mechanism and the risk for CMBs are not clear. The characteristics of carotid lesions have been considered relevant in the relationship between carotid artery atherosclerosis and the presence of CMBs. The potential association between carotid IPH histologically defined and CMBs has not been investigated yet. Purpose We have previously reported the prevalence of IPH in patients with non-obstructive carotid disease in patients who underwent carotid endarterectomy (CEA). In this study, we aimed to investigate whether the presence and the extent of carotid IPH are related to the existence of CMBs. We hypothesized that patients with carotid IPH would have a higher risk of CMBs. Methods This retrospective study enrolled 101 consecutive patients undergoing CEA with symptomatic (including ischemic stroke, TIA, and amaurosis fugax) or asymptomatic ipsilateral carotid artery disease. Carotid plaque specimens were collected at CEA from all the patients and stained with Movat Pentachrome to identify the presence and the extent (%) of IPH. Neck CTA was obtained to measure the degree of carotid stenosis. Brain MRI was pre-surgically performed and CMBs were studied using T2*-weighted gradient-recalled echo (GRE) or susceptibility-weighted imaging (SWI) sequence. The CMBs were counted and localized. Clinical and biochemical data, comorbidities, and medications were recorded. The association between carotid IPH and CMBs was examined adjusted for other risk factors. Results The presence of carotid IPH was in 57 (56.4%) patients. CMBs were more observed in patients with carotid IPH compared to those without IPH [19 (33.3%) vs 5 (11.4%); p=0.010]. Logistic regression analysis demonstrated an association between the extent of IPH in the carotid atheroma and the presence of CMBs [OR 1.051 (95% CI 1.012–1.090); p=0.009]. Moreover, the carotid IPH extent was associated with the number of CMBs (p=0.004). In patients with CMBs, the median degree of ipsilateral carotid stenosis was 40% (35–65%) and it was 70% (50–80%) in those without CMBs, with a significant difference between the two groups (p=0.049). Conclusions In patients undergoing CEA, the histologically defined presence of carotid IPH and its extent are associated with CMBs on brain MR imaging. CMBs may be a potential mechanism for cerebrovascular events in patients with carotid atherosclerotic IPH and they may be an imaging marker that can distinguish the severity of the carotid artery disease. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Mayo Clinic Foundation

Aneurysms associated with a vertebrobasilar fenestration are rare lesions and can grow to a giant size, presenting significant therapeutic challenges. Endovascular treatment of these aneurysms has traditionally been with coiling; however, flow diverter placement within the fenestration arms has recently proven to be a viable treatment strategy. The authors present a case of a giant vertebrobasilar fenestration aneurysm in a patient presenting with a cranial nerve VI palsy. The lesion was treated by using a combination of flow diverter placement and vertebral artery sacrifice. The nuances of flow diversion therapy for these aneurysms and the management of intra- and postoperative complications are discussed. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2256

Background: Uric acid (UA) concentration within carotid plaque and its association with cerebrovascular events have not been detected or quantified. Systemically, serum UA is a marker of inflammation and risk factor for atherosclerosis. However, its association with carotid plaque instability and stroke pathogenesis remains unclear. In patients undergoing carotid endarterectomy, we aimed to determine whether UA is present differentially in symptomatic versus asymptomatic carotid plaques and whether serum UA is associated with cerebrovascular symptoms (stroke, transient ischemic attack, or amaurosis fugax). Methods: Carotid atherosclerotic plaques were collected during carotid endarterectomy. The presence of UA was assessed using Gomori methenamine silver staining as well as anti-UA immunohistochemical staining and its quantity measured using an enzymatic colorimetric assay. Clinical information was obtained through a retrospective review of data. Results: UA was more commonly detected in symptomatic (n=23) compared with asymptomatic (n=9) carotid plaques by Gomori methenamine silver (20 [86.9%] versus 2 [22.2%]; P =0.001) and anti-UA immunohistochemistry (16 [69.5%] versus 1 [11.1%]; P =0.004). UA concentration was higher in symptomatic rather than asymptomatic plaques (25.1 [9.5] versus 17.9 [3.8] µg/g; P =0.021). Before carotid endarterectomy, serum UA levels were higher in symptomatic (n=341) compared with asymptomatic (n=146) patients (5.9 [interquartile range, 4.6–6.9] mg/dL versus 5.2 [interquartile range, 4.6–6.2] mg/dL; P =0.009). Conclusions: The current study supports a potential role of UA as a potential tissue participant and a systemic biomarker in the pathogenesis of carotid atherosclerosis. UA may provide a mechanistic explanation for plaque instability and subsequent ischemic cerebrovascular events.

Purpose: Cervical artery dissection (CAD) represents a unique clinical entity with a high risk of ischemic stroke. Vitamin K antagonists (VKA) showed good efficacy in CAD management but are cumbersome to use with potentially higher bleeding rates. Novel oral anticoagulants (NOAC) are easier to use and may have similar effects but lower hemorrhagic risk. In this systematic review, we compare the efficacy of NOAC to VKA as a potential alternative treatment. Methods: The literature was searched on Pubmed, PMC, and Embase via API through the Nested Knowledge AutoLit software in February 2022 for studies evaluating both NOAC and VKA. Baseline characteristics, clinical and radiographic outcomes, and hemorrhagic and ischemic complications were collected for single and double-arm studies and analyzed using random-effect subgroup meta-analysis. Findings: Overall, 11 studies were included with 699 patients treated with VKA and 53 treated with NOAC (from three studies; two were head-to-head comparative studies). There was no statistical difference in the baseline characteristics of VKA and NOAC patients. The rates of TIA/stroke in VKA and NOAC groups were 12.3% (95% CI; 0%, 28.6%) and 5.7% (95% CI; 0%, 12.2%), respectively. Major bleeding or intracranial bleeding were comparable between groups. Lesions treated with VKA showed angiographic recanalization with a rate of 51.4% (95% CI; 35.6%, 67.1%) and for those treated with NOAC was 58.4% (95% CI; 23.9%, 93.9%). The rates of good clinical outcomes were 79.9% (95% CI; 67.6%, 92.2%) in the VKA group and 91.4% (95% CI; 78.1%, 100%) in NOAC. No statistical difference was noted among any of the outcomes between the two treatment groups. Discussion and conclusion: We highlighted comparable efficacy and safety of NOAC to VKA for stroke prevention in CAD. Further head-to-head studies are warranted to validate these results.

Arteriovenous malformations (AVMs) are some of the most challenging surgical entities. Like any challenging surgical procedure, AVM surgery is a series of basic but fundamental steps, each with its own nuances. Despite a myriad of published material regarding AVMs, there are few succinct illustrated summaries of these steps with an accompanying elucidation of the most common pitfalls. This paper provides a step-by-step description and illustration of the basic surgical principles of AVM microsurgical resection, focusing on the main key points and addressing the critical issues that surround this surgery. Deep anatomical knowledge and presurgical planning of these basic steps, combined with good contingency management skills, are paramount for an effective and safe AVM surgery.

OBJECTIVE Arteriovenous malformations (AVMs) are a major cause of intracerebral hemorrhage in children, resulting in significant morbidity and mortality. Moreover, the rate of AVM recurrence in children is significantly higher than in adults. The aim of this study was to define the risk of delayed pediatric AVM (pAVM) recurrence following confirmed radiological obliteration. Further understanding of this risk could inform the role of long-term radiological surveillance. METHODS The authors conducted a retrospective review of ruptured and unruptured pAVM cases treated at a single tertiary care referral center between 1994 and 2019. Demographics, clinical characteristics, treatment modalities, and AVM recurrence were analyzed. RESULTS A total of 102 pediatric patients with intracranial AVMs, including 52 (51%) ruptured cases, were identified. The mean patient age at presentation was 11.2 ± 4.4 years, and 51 (50%) patients were female. The mean nidus size was 2.66 ± 1.44 cm. The most common Spetzler-Martin grades were III (32%) and II (31%). Stereotactic radiosurgery was performed in 69.6% of patients. AVM obliteration was radiologically confirmed in 68 (72.3%) of 94 patients with follow-up imaging, on angiography in 50 (73.5%) patients and on magnetic resonance imaging in 18 (26.5%). AVM recurrence was identified in 1 (2.3%) of 43 patients with long-term surveillance imaging over a mean follow-up of 54.7 ± 38.9 months (range 2–153 months). This recurrence was identified in a boy who had presented with a ruptured AVM and had been surgically treated at 5 years of age. The AVM recurred 54 months after confirmed obliteration on surveillance digital subtraction angiography. Two other cases of presumed AVM recurrence following resection in young children were excluded from recurrence analysis because of incomplete sets of imaging available for review. CONCLUSIONS AVM recurrence following confirmed obliteration on imaging is a rare phenomenon, though it occurs more frequently in the pediatric population. Regular long-term follow-up with dedicated surveillance angiography is recommended even after obliteration following resection.