Citations

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.

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.

OBJECTIVEOver the last half century, there have been isolated case reports of purely arterial malformations. In this study, the authors report a consecutive series of patients with pure arterial malformations, emphasizing the clinical and radiological features of these lesions.METHODSPure arterial malformations were defined as dilated, overlapping, and tortuous arteries with a coil-like appearance and/or a mass of arterial loops without any associated venous component. Demographic characteristics of the patients, cardiovascular risk factors, presentation, radiological characteristics, and follow-up data were collected. Primary outcomes were new neurological symptoms including disability, stroke, and hemorrhage.RESULTSTwelve patients meeting the criteria were identified. Ten patients were female (83.3%) and 2 were male (16.6%). Their mean age at diagnosis was 26.2 ± 11.6 years. The most common imaging indication was headache (7 patients [58.3%]). In 3 cases the pure arterial malformation involved the anterior cerebral arteries (25.0%); in 4 cases the posterior communicating artery/posterior cerebral artery (33.3%); in 2 cases the middle cerebral artery (16.6%); and in 1 case each, the superior cerebellar artery, basilar artery/anterior inferior cerebellar artery, and posterior inferior cerebellar artery. The mean maximum diameter of the malformations was 7.2 ± 5.0 mm (range 3–16 mm). Four lesions had focal aneurysms associated with the pure arterial malformation, and 5 were partially calcified. In no cases was there associated intracranial hemorrhage or infarction. One patient underwent treatment for the pure arterial malformation. All 12 patients had follow-up (mean 29 months, median 19 months), and there were no cases of disability, stroke, or hemorrhage.CONCLUSIONSPure arterial malformations are rare lesions that are often detected incidentally and probably have a benign natural history. These lesions can affect any of the intracranial arteries and are likely best managed conservatively.

Aim To describe the impact of steps towards reduction of procedural doses of radiation during neuroendovascular procedures. Methods Phantom exposures under controlled circumstances were performed using a Rando-Alderson adult-sized head phantom. Customized imaging protocols were devised for pediatric and adult imaging and implemented in clinical use. Outcome data for estimated skin doses (ESD) and dose–area product (DAP) following pediatric and adult diagnostic and interventional procedures over 4.5 years were analyzed retrospectively. Results Dose estimates were reduced by 50% or more after introduction of customized imaging protocols in association with modification of personnel behavior compared with doses recorded with previously used vendor-recommended protocols. Discussion Substantial reductions in radiation use during neuroendovascular procedures can be achieved through a combination of equipment modification and operator behavior.

Background and Purpose— There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). Methods— A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. Results— Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66–2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22–2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48–0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29–0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67–1.06). Conclusions— Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.