Endovascular Treatment of Supra-Aortic Extracranial Stenoses in Patients with Vertebrobasilar Insufficiency Symptoms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zaytsev, A.Y., E-mail: cir-auz@mail.ru; Stoyda, A.Y.; Smirnov, V.E.

2006-10-15

Purpose. Stenoses and thromboses of vessels feeding the vertebrobasilar territory can evoke serious disturbances including ischemic stroke. We present our experience of endovascular interventions for patients with signs of vertebrobasilar insufficiency (VBI) resulted from subclavian, vertebral and brachiocephalic arterial stenoses. Methods. Twenty-one patients (10 men) aged from 35 to 84 years (mean 64.3 years) with symptoms compatible with VBI underwent balloon angioplasty and stenting of subclavian (SA), innominate (IA) and vertebral (VA) arteries. Procedures were done by radiologists experienced in systematic stenting of the lesions. VBI was manifested by persistent signs in 15 patients, and by transitory ischemic attacks inmore » the posterior circulatory territory in 4 (19%). Two patients (10%) experienced ischemic strokes (in the vertebrobasilar circulation in both cases). In 3 patients (14%) VBI was accompanied by upper limb vascular insufficiency symptoms. All cases were resistant to medical treatment. A neurologist assessed complaints, initial VBI signs and their alteration after intervention in all patients. Outcomes were measured with the 5-point scale suggested by Malek et al.: (1) excellent result (asymptomatic, no neurologic deficits and no symptoms of vertebrobasilar ischemia); (2) good (no neurologic deficits, at most one transient episode of vertebrobasilar ischemia over a period of 3 months after treatment); (3) fair (minimal neurologic deficit and at most one transient episode per month of vertebrobasilar ischemia); (4) poor (no improvement compared with neurologic status before treatment and/or persistent symptoms of vertebrobasilar ischemia); (5) death (regardless of cause). Endovascular treatment was performed for SA stenosis in 15 patients, for SA occlusion in 2, for IA stenosis in 2, and for VA stenosis in 2. There were 15 cases of atherosclerosis, 2 of aortoarteritis, 4 of proximal SA kinking. SA and IA stenoses ranged from 60% to 100

Intracranial arteries in individuals with the elastin gene hemideletion of Williams syndrome.

PubMed

Wint, D P; Butman, J A; Masdeu, J C; Meyer-Lindenberg, A; Mervis, C B; Sarpal, D; Morris, C A; Berman, K F

2014-01-01

Williams syndrome, a rare genetic disorder with a striking neurobehavioral profile characterized by extreme sociability and impaired visuospatial construction abilities, is caused by a hemideletion that includes the elastin gene, resulting in frequent supravavular aortic stenosis and other stenotic arterial lesions. Strokes have been reported in Williams syndrome. Although the extracranial carotid artery has been studied in a sample of patients with Williams syndrome, proximal intracranial arteries have not. Using MRA, we studied the intracranial vessels in 27 participants: 14 patients with Williams syndrome (age range, 18-44 years; mean age, 27.3 ± 9.1; 43% women) and 13 healthy control participants with similar age and sex distribution (age range, 22-52 years; mean age, 33.4 ± 7.6; 46% women). All participants with Williams syndrome had hemideletions of the elastin gene. Blinded to group allocation or to any other clinical data, a neuroradiologist determined the presence of intracranial vascular changes in the 2 groups. The Williams syndrome group and the healthy control group had similar patency of the proximal intracranial arteries, including the internal carotid and vertebral arteries; basilar artery; and stem and proximal branches of the anterior cerebral artery, MCA, and posterior cerebral arteries. The postcommunicating segment of the anterior cerebral artery was longer in the Williams syndrome group. Despite the elastin haploinsufficiency, the proximal intracranial arteries in Williams syndrome preserve normal patency.

Association of Brachial-Ankle Pulse Wave Velocity with Asymptomatic Intracranial Arterial Stenosis in Hypertension Patients.

PubMed

Wang, Yan; Zhang, Jin; Qain, Yuesheng; Tang, Xiaofeng; Ling, Huawei; Chen, Kemin; Li, Yan; Gao, Pingjin; Zhu, Dingliang

2016-08-01

Intracranial arterial stenosis is a common cause of ischemic stroke in Asians. We therefore sought to explore the relationship of brachial-ankle pulse wave velocity and intracranial arterial stenosis in 834 stroke-free hypertensive patients. Intracranial arterial stenosis was evaluated through computerized tomographic angiography. Brachial-ankle pulse wave velocity was measured by an automated cuff device. The top decile of brachial-ankle pulse wave velocity was significantly associated with intracranial arterial stenosis (P = .027, odds ratio = 1.82; 95% confidence interval: 1.07-3.10). The patients with the top decile of brachial-ankle pulse wave velocity showed 56% higher risk for the presence of intracranial arterial stenosis to the whole population, which was more significant in patients younger than 65 years old. We also found that brachial-ankle pulse wave velocity related to both intracranial arterial stenosis and homocysteine. Our study showed the association of brachial-ankle pulse wave velocity with asymptomatic intracranial arterial stenosis in hypertension patients, especially in relative younger subjects. Brachial-ankle pulse wave velocity might be a relatively simple and repeatable measurement to detect hypertension patients in high risk of intracranial arterial stenosis. Copyright © 2016. Published by Elsevier Inc.

Intracranial Arterial Dissection Mimicking a Saccular Aneurysm: Clinical Image.

PubMed

Rodríguez-Hernández, Ana; Torné, Ramon; Arikan, Fuat

2017-02-01

This report portrays our pitfall in the initial diagnosis of an intracranial arterial dissection that we misinterpreted as a saccular aneurysm. Intracranial arterial dissections presenting with convexity subarachnoid hemorrhage are rare, thus being easily mistaken with mild traumatic head injuries and therefore preventing transfer to a tertiary hospital. Even in those cases where the dissection is suspected and the patient is transferred to the appropriate facility for a diagnostic angiogram, misdiagnosis is not infrequent. The typical radiographic signs such as the double lumen or "pearl and string" are scarcely present in the diagnostic angiogram. Thrombus within the dissected segment can be mistaken by vasospasm and may even reveal fake images of saccular aneurysms, thus prompting inadequate endovascular or surgical treatment. The case reported here illustrates all these likely pitfalls in the diagnosis and management of intracranial arterial dissections. Copyright © 2016 Elsevier Inc. All rights reserved.

Basic mechanisms in intracranial large-artery atherosclerosis: advances and challenges.

PubMed

Arenillas, Juan F; Alvarez-Sabín, José

2005-01-01

Intracranial large-artery atherosclerosis is a major cause of ischemic stroke worldwide. Patients affected by this disease are at a high risk of suffering recurrent ischemic events despite antithrombotic therapy. Progression and a greater extent of intracranial atherosclerosis imply a higher risk for recurrence. Studies performed by our group in patients with symptomatic intracranial large-artery atherosclerosis have shown that: (1) C-reactive protein predicts its progression and recurrence, suggesting that inflammation may play a deleterious role in this condition; (2) a high level of the anti-angiogenic endostatin is also associated with a progressive and recurrent intracranial atherosclerosis, which might support a beneficial role for angiogenesis in this group of patients; and (3) elevated lipoprotein(a) concentration and diabetes mellitus characterize those patients with a higher number of intracranial stenoses. 2005 S. Karger AG, Basel

Characteristics of time-varying intracranial pressure on blood flow through cerebral artery: A fluid-structure interaction approach.

PubMed

Syed, Hasson; Unnikrishnan, Vinu U; Olcmen, Semih

2016-02-01

Elevated intracranial pressure is a major contributor to morbidity and mortality in severe head injuries. Wall shear stresses in the artery can be affected by increased intracranial pressures and may lead to the formation of cerebral aneurysms. Earlier research on cerebral arteries and aneurysms involves using constant mean intracranial pressure values. Recent advancements in intracranial pressure monitoring techniques have led to measurement of the intracranial pressure waveform. By incorporating a time-varying intracranial pressure waveform in place of constant intracranial pressures in the analysis of cerebral arteries helps in understanding their effects on arterial deformation and wall shear stress. To date, such a robust computational study on the effect of increasing intracranial pressures on the cerebral arterial wall has not been attempted to the best of our knowledge. In this work, fully coupled fluid-structure interaction simulations are carried out to investigate the effect of the variation in intracranial pressure waveforms on the cerebral arterial wall. Three different time-varying intracranial pressure waveforms and three constant intracranial pressure profiles acting on the cerebral arterial wall are analyzed and compared with specified inlet velocity and outlet pressure conditions. It has been found that the arterial wall experiences deformation depending on the time-varying intracranial pressure waveforms, while the wall shear stress changes at peak systole for all the intracranial pressure profiles. © IMechE 2015.

Wall-to-lumen ratio of intracranial arteries measured by indocyanine green angiography

PubMed Central

Nakagawa, Daichi; Shojima, Masaaki; Yoshino, Masanori; Kin, Taichi; Imai, Hideaki; Nomura, Seiji; Saito, Toki; Nakatomi, Hirofumi; Oyama, Hiroshi; Saito, Nobuhito

2016-01-01

Background: The wall-to-lumen ratio (WLR) is an important parameter in vascular medicine because it indicates the character of vascular wall as well as the degree of stenosis. Despite the advances in medical imaging technologies, it is still difficult to measure the thin-walled normal intracranial arteries, and the reports on the WLR of normal intracranial artery are limited. It might be possible to calculate the WLR using the indocyanine green (ICG) angiography, which is used to observe intracranial vessels during microsurgery. Purpose: To evaluate the WLR of normal intracranial arteries using ICG angiography. Materials and Methods: From the three cases in which ICG angiography was recorded with a ruler during microsurgery, 20 measurement points were chosen for the analysis. The ICG was injected intravenously with a dose of 0.2 mg/kg, and the vessels were inspected at high magnification using an operating microscope equipped with near-infrared illumination system. The vessel outer diameter and the luminal diameter were measured using the images before and after the ICG arrival based on the pixel ratio method using a ruler as reference, respectively. The WLR was calculated as 0.5 × (vessel outer diameter − vessel luminal diameter). Results: The WLR (mean ± standard deviation) of normal intracranial arteries was 0.086 ± 0.022. The WLR tended to be high in small arteries. Conclusion: The WLR of normal intracranial arteries calculated using ICG angiography was consistent with the WLR reported in the previous reports based on human autopsy. PMID:27695538

Association between an aplastic basilar artery, unaccompanied by a primitive carotid-vertebrobasilar anastomosis, and multiple aneurysms on the dominant posterior communicating artery.

PubMed

Behari, Sanjay; Krishna, Himanshu; Kumar, Marakani V Kiran; Sawlani, Vijay; Phadke, Rajendra V; Jain, Vijendra K

2004-05-01

Basilar artery (BA) aplasia when unaccompanied by a primitive carotid-vertebrobasilar anastomosis is exceedingly rare. The association of BA aplasia with two aneurysms on the dominant posterior communicating artery (PCoA) has not been previously reported. This 40-year-old man presented in a state of drowsiness and responded to simple commands only after being coaxed. He had complete left cranial third nerve palsy, right hemiparesis, and persisting signs of meningeal irritation. A computerized tomography (CT) scan revealed subarachnoid and intraventricular hemorrhage. An angiogram revealed BA aplasia. The right PCoA followed a sinuous course with multiple loops and provided the dominant supply to the posterior circulation. This vessel harbored two aneurysms, one at the origin of the PCoA from the internal carotid artery and the other at the looping segment just proximal to the brainstem. The left PCoA was extremely thin. The pterional transsylvian approach was used to clip the two aneurysms on the PCoA. The hemodynamic changes produced by the BA aplasia may have produced alterations in the cerebral vasculature leading to aneurysm formation and consequent subarachnoid hemorrhage.

CO-LOCALIZATION OF THE VANILLOID CAPSAICIN RECEPTOR AND SUBSTANCE P IN SENSORY NERVE FIBERS INNERVATING COCHLEAR AND VERTEBRO-BASILAR ARTERIES

PubMed Central

VASS, Z.; DAI, C. F.; STEYGER, P. S.; JANCSÓ, G.; TRUNE, D. R.; NUTTALL, A. L.

2014-01-01

Evidence suggests that capsaicin-sensitive substance P (SP)-containing trigeminal ganglion neurons innervate the spiral modiolar artery (SMA), radiating arterioles, and the stria vascularis of the cochlea. Antidromic electrical or chemical stimulation of trigeminal sensory nerves results in neurogenic plasma extravasation in inner ear tissues. The primary aim of this study was to reveal the possible morphological basis of cochlear vascular changes mediated by capsaicin-sensitive sensory nerves. Therefore, the distribution of SP and capsaicin receptor (transient receptor potential vanilloid type 1—TRPV1) was investigated by double immunolabeling to demonstrate the anatomical relationships between the cochlear and vertebro-basilar blood vessels and the trigeminal sensory fiber system. Extensive TRPV1 and SP expression and co-localization were observed in axons within the adventitial layer of the basilar artery, the anterior inferior cerebellar artery, the SMA, and the radiating arterioles of the cochlea. There appears to be a functional relationship between the trigeminal ganglion and the cochlear blood vessels since electrical stimulation of the trigeminal ganglion induced significant plasma extravasation from the SMA and the radiating arterioles. The findings suggest that stimulation of paravascular afferent nerves may result in permeability changes in the basilar and cochlear vascular bed and may contribute to the mechanisms of vertebro-basilar type of headache through the release of SP and stimulation of TPVR1, respectively. We propose that vertigo, tinnitus, and hearing deficits associated with migraine may arise from perturbations of capsaicin-sensitive trigeminal sensory ganglion neurons projecting to the cochlea. PMID:15026132

Hydrocephalus as a rare compilation of vertebrobasilar dolichoectasia: A case report and review of the literature.

PubMed

Ebrahimzadeh, Keveh; Bakhtevari, Mehrdad H; Shafizad, Misagh; Rezaei, Omidvar

2017-01-01

Vertebrobasilar dolichoectasia (VBD) is a rare disease characterized by significant expansion, elongation, and tortuosity of the vertebrobasilar arteries. Hydrocephalus is a rare compilation of VBD. In this study, we report a 68-year-old male presenting with headache, progressive decreased visual acuity, memory loss, imbalance while walking, and episodes of urinary incontinency. The patient was diagnosed with dolichoectasia of basilar artery causing compression of the third ventricular outflow and thus, presenting with hydrocephalus documented with brain computed tomography scan and brain magnetic resonance imaging. The patient underwent surgical operation and ventriculoperitoneal shunt placement. In the case of hydrocephalus or normal pressure hydrocephalous, VBD should be considered as a differential diagnosis.

The Incidence and Risk Factors of In-Stent Restenosis for Vertebrobasilar Artery Stenting.

PubMed

Zheng, Dai; Mingyue, Zhu; Wei, Shi; Min, Li; Wanhong, Chen; Qiliang, Dai; Yongjun, Jiang; Xinfeng, Liu

2018-02-01

In-stent restenosis (ISR) remains a challenge for vertebrobasilar artery stenting (VBAS). We aimed to investigate the incidence and risk factors of ISR. This was a retrospective study. From July 28, 2005, to July 30, 2015, patients who received VBAS with an angiographic follow-up time of 6 to 12 months after surgery were enrolled. The clinical and angiographic issues were recorded and analyzed. In total, 283 patients with 335 stents were incorporated into the study. Vertebral ostial lesions accounted for 73.4% (246/335) of the lesions. During the follow-up period, 58 patients with 60 stents experienced ISR (>50%). Stepwise logistic regression analysis showed that the degree of residual stenosis, stent diameter, and alcohol consumption were independent predictors of ISR. Our study demonstrated the incidence and risk factors of ISR after VBAS. This retrospective study with the largest cohort to date provided insight into the occurrence of ISR after VBAS. Copyright © 2017 Elsevier Inc. All rights reserved.

Hydrocephalus as a rare compilation of vertebrobasilar dolichoectasia: A case report and review of the literature

PubMed Central

Ebrahimzadeh, Keveh; Bakhtevari, Mehrdad H.; Shafizad, Misagh; Rezaei, Omidvar

2017-01-01

Background: Vertebrobasilar dolichoectasia (VBD) is a rare disease characterized by significant expansion, elongation, and tortuosity of the vertebrobasilar arteries. Hydrocephalus is a rare compilation of VBD. Case Description: In this study, we report a 68-year-old male presenting with headache, progressive decreased visual acuity, memory loss, imbalance while walking, and episodes of urinary incontinency. The patient was diagnosed with dolichoectasia of basilar artery causing compression of the third ventricular outflow and thus, presenting with hydrocephalus documented with brain computed tomography scan and brain magnetic resonance imaging. The patient underwent surgical operation and ventriculoperitoneal shunt placement. Conclusion: In the case of hydrocephalus or normal pressure hydrocephalous, VBD should be considered as a differential diagnosis. PMID:29184707

Causes and Severity of Ischemic Stroke in Patients with Symptomatic Intracranial Arterial Stenosis

PubMed Central

Famakin, Bolanle M; Chimowitz, Marc I; Lynn, Michael J; Stern, Barney J; George, Mary G.

2009-01-01

Background and purpose There are limited data on the causes and severity of subsequent stroke in patients presenting initially with TIA or stroke attributed to intracranial arterial stenosis. Methods We evaluated the location, type (lacunar vs. non-lacunar), cause, and severity of stroke in patients who had an ischemic stroke endpoint in the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial. Results Of the 569 patients enrolled in the WASID trial, 106 patients (18.6%) had an ischemic stroke during a mean follow-up of 1.8 years. Stroke occurred in the territory of the symptomatic artery in 77 (73%) of 106 patients. Among the 77 strokes in the territory, 70 (91%) were non-lacunar and 34 (44%) were disabling. Stroke out of the territory of the symptomatic artery occurred in 29 (27%) of 106 patients. Among these 29 strokes, 24 (83%) were non-lacunar, 14 (48%) were due to previously asymptomatic intracranial stenosis, and 9 (31%) were disabling. Conclusions Most subsequent strokes in patients with symptomatic intracranial artery stenosis are in the same territory and non-lacunar, and nearly half of the strokes in the territory are disabling. The most commonly identified cause of stroke out of the territory was a previously asymptomatic intracranial stenosis. Penetrating artery disease was responsible for a low number of strokes. PMID:19407228

Vertebrobasilar system computed tomographic angiography in central vertigo

PubMed Central

Paşaoğlu, Lale

2017-01-01

Abstract The incidence of vertigo in the population is 20% to 30% and one-fourth of the cases are related to central causes. The aim of this study was to evaluate computed tomography angiography (CTA) findings of the vertebrobasilar system in central vertigo without stroke. CTA and magnetic resonance images of patients with vertigo were retrospectively evaluated. One hundred twenty-nine patients suspected of having central vertigo according to history, physical examination, and otological and neurological tests without signs of infarction on diffusion-weighted magnetic resonance imaging were included in the study. The control group included 120 patients with similar vascular disease risk factors but without vertigo. Vertebral and basilar artery diameters, hypoplasias, exit-site variations of vertebral artery, vertebrobasilar tortuosity, and stenosis of ≥50% detected on CTA were recorded for all patients. Independent-samples t test was used in variables with normal distribution, and Mann–Whitney U test in non-normal distribution. The difference of categorical variable distribution according to groups was analyzed with χ2 and/or Fisher exact test. Vertebral artery hypoplasia and ≥50% stenosis were seen more often in the vertigo group (P = 0.000, <0.001). Overall 78 (60.5%) vertigo patients had ≥50% stenosis, 54 (69.2%) had stenosis at V1 segment, 9 (11.5%) at V2 segment, 2 (2.5%) at V3 segment, and 13 (16.6%) at V4 segment. Both vertigo and control groups had similar basilar artery hypoplasia and ≥50% stenosis rates (P = 0.800, >0.05). CTA may be helpful to clarify the association between abnormal CTA findings of vertebral arteries and central vertigo. This article reveals the opportunity to diagnose posterior circulation abnormalities causing central vertigo with a feasible method such as CTA. PMID:28328808

Vertebrobasilar system computed tomographic angiography in central vertigo.

PubMed

Paşaoğlu, Lale

2017-03-01

The incidence of vertigo in the population is 20% to 30% and one-fourth of the cases are related to central causes. The aim of this study was to evaluate computed tomography angiography (CTA) findings of the vertebrobasilar system in central vertigo without stroke.CTA and magnetic resonance images of patients with vertigo were retrospectively evaluated. One hundred twenty-nine patients suspected of having central vertigo according to history, physical examination, and otological and neurological tests without signs of infarction on diffusion-weighted magnetic resonance imaging were included in the study. The control group included 120 patients with similar vascular disease risk factors but without vertigo. Vertebral and basilar artery diameters, hypoplasias, exit-site variations of vertebral artery, vertebrobasilar tortuosity, and stenosis of ≥50% detected on CTA were recorded for all patients. Independent-samples t test was used in variables with normal distribution, and Mann-Whitney U test in non-normal distribution. The difference of categorical variable distribution according to groups was analyzed with χ and/or Fisher exact test.Vertebral artery hypoplasia and ≥50% stenosis were seen more often in the vertigo group (P = 0.000, <0.001). Overall 78 (60.5%) vertigo patients had ≥50% stenosis, 54 (69.2%) had stenosis at V1 segment, 9 (11.5%) at V2 segment, 2 (2.5%) at V3 segment, and 13 (16.6%) at V4 segment. Both vertigo and control groups had similar basilar artery hypoplasia and ≥50% stenosis rates (P = 0.800, >0.05).CTA may be helpful to clarify the association between abnormal CTA findings of vertebral arteries and central vertigo.This article reveals the opportunity to diagnose posterior circulation abnormalities causing central vertigo with a feasible method such as CTA.

Severity assessment of intracranial large artery stenosis by pressure gradient measurements: A feasibility study.

PubMed

Han, Yun-Fei; Liu, Wen-Hua; Chen, Xiang-Liang; Xiong, Yun-Yun; Yin, Qin-; Xu, Ge-Lin; Zhu, Wu-Sheng; Zhang, Ren-Liang; Ma, Min-Min; Li, Min-; Dai, Qi-Liang; Sun, Wen-; Liu, De-Zhi; Duan, Li-Hui; Liu, Xin-Feng

2016-08-01

Fractional flow reserve (FFR)-guided revascularization strategy is popular in coronary intervention. However, the feasibility of assessing stenotic severity in intracranial large arteries using pressure gradient measurements still remains unclear. Between March 2013 and May 2014, 12 consecutive patients with intracranial large artery stenosis (including intracranial internal carotid artery, middle cerebral M1 segment, intracranial vertebral artery, and basilar artery) were enrolled in this study. The trans-stenotic pressure gradient was measured before and/or after percutaneous transluminal angioplasty and stenting (PTAS), and was then compared with percent diameter stenosis. A Pd /Pa cut-off of ≤0.70 was used to guide stenting of hemodynamically significant stenoses. The device-related and procedure-related serious adverse events and recurrent cerebral ischemic events were recorded. The target vessel could be reached in all cases. No technical complications occurred due to the specific study protocol. Excellent pressure signals were obtained in all patients. For seven patients who performed PTAS, the mean pre-procedural pressure gradient decreased from 59.0 ± 17.2 to 13.3 ± 13.6 mm Hg after the procedure (P < 0.01). Only one patient who refused stenting experienced a TIA event in the ipsilateral MCA territory. No recurrent ischemic event was observed in other patients. Mean trans-stenotic pressure gradients can be safely and easily measured with a 0.014-inch fluid-filled guide wire in intracranial large arteries. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Middle cerebral arterial flow changes on transcranial color and spectral Doppler sonography in patients with increased intracranial pressure.

PubMed

Wang, Yu; Duan, Yun-You; Zhou, Hai-Yan; Yuan, Li-Jun; Zhang, Li; Wang, Wei; Li, Li-Hong; Li, Liang

2014-12-01

Intracranial pressure usually increases after severe brain injury. However, a method for noninvasive evaluation of intracranial pressure is still lacking. The purpose of this study was to explore the potential role of transcranial color Doppler sonography in assessing intracranial pressure by observing the middle cerebral artery blood flow parameters in patients with increased intracranial pressure of varying etiology. The hemodynamic changes in the middle cerebral artery in patients with varying degrees of increased intracranial pressure were investigated by transcranial color Doppler sonography in 93 patients who had emergency surgery for brain injury. Middle cerebral artery Doppler flow spectra changed regularly as intracranial pressure increased. The pulsatility index (PI) and resistive index (RI) had a significantly positive correlation with intracranial pressure (r = 0.90 and 0.89, respectively; P< .001), whereas the middle cerebral artery diastolic velocity showed a significant negative correlation with intracranial pressure (r = -0.52; P< .01). A receiver operating characteristic curve showed that the RI and PI cutoff values were 0.705 and 1.335, respectively, for predicting increased intracranial pressure, with sensitivity of 0.885 and specificity of 0.970. In addition to the PI and RI, middle cerebral artery diastolic flow velocity measurement by transcranial color Doppler sonography may also be a useful variable for evaluating intracranial pressure in patients with acute brain injury. © 2013 by the American Institute of Ultrasound in Medicine.

[Analysis on Clinical Characteristic and Risk Factors of Patients Coexistence of Cerebral Artery Stenosis with Unruptured Intracranial Aneurysm].

PubMed

Zhao, Hai-Yan; Han, Jin-Tao; Fan, Dong-Sheng

2017-09-01

To analyze the incidence of intracranial unruptured aneurysms in patients with intracranial artery stenosis,clinical features,and investigate the risk factors for unruptured intracranial aneurysms. Medical records from all patients performed with digital subtraction angiography (DSA) who had been treated at Peking University Third Hospital,China,from January 2012 to December 2015 were retrospectively reviewed to identify cases coexistence with cerebral artery stenosis and unruptured intracranial aneurysm. Of 273 patients with cerebral artery stenosis (≥50%),intracranial unruptured aneurysms was observed in 17 cases (6.23%) from age of 45 to 78,among them 8 (47.06%) were female and 9 (52.94%) were male. The incidence of unruptured intracranial aneurysm in male patients was 4.17% (9/216),and that of female was 14.4% (8/57). There was statistically significant difference between the male and female incidence of intracranial aneurysm ( P <0.05). Of these 17 patients,16 (94.12%) aneurysms were located in the internal carotid artery (ICA) system,1 (5.88%) aneurysm was located at the tip of the basilar artery. In 11 cases (64.71%),aneurysms were located at the distal of the stenotic vessels,2 (11.76%) were located at the proximal of the stenotic vessels,and 4 cases (23.53%) of which the aneurysm and stenosis were not in the same artery. Logistic multivariate analysis showed that gender was an independent risk factor for aneurysms in patients with cerebral arterial stenosis. In the intracranial artery stenosis atients,the possibility of the occurrence of the aneurysm is much higher than the general population,and women were more prominent than man. Sex is an independent risk factor for aneurysms in patients with cerebral arterial stenosis.

High frequency of intracranial arterial stenosis and cannabis use in ischaemic stroke in the young.

PubMed

Wolff, Valérie; Armspach, Jean-Paul; Beaujeux, Rémy; Manisor, Monica; Rouyer, Olivier; Lauer, Valérie; Meyer, Nicolas; Marescaux, Christian; Geny, Bernard

2014-01-01

Leading aetiologies of ischaemic stroke in young adults are cervico-cerebral arterial dissections and cardio-embolism, but the causes remain undetermined in a considerable proportion of cases. In a few reports, intracranial arterial stenosis has been suggested to be a potential cause of ischaemic stroke in young adults. The aim of our work was to evaluate the frequency, characteristics and risk factors of intracranial arterial stenosis in a prospective series of young ischaemic stroke patients. The study was based on a prospective consecutive hospital-based series of 159 patients aged 18-45 years who were admitted to our unit for an acute ischaemic stroke from October 2005 to December 2010. A structured questionnaire was used in order to assess common vascular risk factors such as hypertension, diabetes, hypercholesterolemia, use of tobacco, alcohol and illicit drugs, migraine, and, in women, oral contraceptive use. A systematic screening was performed, including the following: brain magnetic resonance imaging or, if not feasible, brain computed tomography scan, carotid and vertebral Duplex scanning and trans-cranial Doppler sonography, 3D time-of-flight magnetic resonance cerebral angiography or cerebral computed tomography angiography. Long-duration electrocardiography, trans-thoracic and trans-oesophageal echocardiography were performed and laboratory blood investigations were extensive. Urine samples were screened for cannabinoids, cocaine, amphetamine and methylene-dioxy-methamphetamine. When this initial work-up was inconclusive, trans-femoral intra-arterial selective digital subtraction angiography with reconstructed 3D images was performed. In this series, 49 patients (31%) had intracranial arterial stenosis. Other defined causes were found in 91 patients (57%), including cardio-embolism in 32 (20%), cervical dissection in 23 (14%), extracranial atherosclerosis in 7 (4%), haematological disorders in 7 (4%), small vessel disease in 1, and isolated patent

Extracranial-intracranial bypass in medial sphenoid ridge meningioma associated with severe stenosis of the intracranial segments of the internal carotid artery: A case report.

PubMed

Huang, Yabo; Wang, Zhong; Han, Qingdong

2018-06-01

Tumor resection and extracranial-intracranial bypass concerning medial sphenoid ridge meningioma associated with severe stenosis of the internal carotid artery (ICA) of intracranial segments has been rarely presented. Effective treatment as to the complex lesions may be complicated. Tumor resection and cerebrovascular protection should be both taken into consideration. We presented one case of medial sphenoid ridge meningioma associated with severe stenosis of the internal carotid artery of intracranial segments. The patient suffered hyperthyroidism, mirror-image dextrocardia and congenital heart disease atrial septal defect simultaneously. Before the neurosurgical treatment , the colleagues of department of cardiac surgery, anesthesiology and respiratory medicine agreed on our plan of resecting the tumor following the comprehensive evaluation of basal clinical conditions in the patient. For reducing the bleeding intraoperatively, the interventional branch performed digital subtraction angiography(DSA) and found collateral anastomosis between the supplying vessels of left middle meningeal arteries and anterior choroid arteries. No preoperative interventional embolization was determined considering the risk of cerebral ischemia. The following subtotal resection of medial sphenoid ridge meningioma and left extracranial-intracranial bypass were carried out. Additionally, ipsilateral decompressive craniectomy was done. Post-operative imaging Computed tomography (CT), Computed tomography angiography (CTA) and Transcranial Doppler (TCD) indicated subtotal resection of tumor and bypass patency. The patient was discharged with the right limbs of muscle strength of grade IV. The muscle strength of the patient returned to grade V after 6 months of follow-up. Comprehensive treatment of tumor resection and extracranial-intracranial bypass concerning medial sphenoid ridge meningioma associated with severe stenosis of the internal carotid artery of intracranial segments is

Evaluation of the effects of sildenafil citrate (viagra) on vertebral artery blood flow in patients with vertebro-basilar insufficiency.

PubMed

Bozgeyik, Zulkif; Berilgen, Sait; Ozdemir, Huseyin; Tekatas, Aslan; Ogur, Erkin

2008-01-01

To investigate the effects of sildenafil citrate (Viagra) on the vertebral artery blood flow of patients with vertebro-basilar insufficiency (VBI) using color duplex sonography (CDS). The study included 21 patients with VBI (aged 31-76; mean 61.0 +/- 10.5 yrs). We administered a 50 mg oral dose of sildenafil citrate to all patients. Next, we measured the peak systolic velocity (Vmax), end diastolic velocity (Vmin), resistive index (RI), pulsatility index (PI), diameter, area, and flow volume (FV) of vertebral arteries using CDS before the administration of sildenafil citrate; 45 minutes after, and 75 minutes after administration. Statistical testing was performed using SPSS for windows version 11.0. The statistical test used to determine the outcome of the analysis was the repeated measures analysis of variance (ANOVA) test. Compared to the baseline values, the vertebral artery diameter, area, and FV increased significantly following the administration of sildenafil citrate. The diameter, area and FV increased from 3.39 mm at 45 minutes to 3.64 mm at 75 minutes, 9.43 cm(2) to 10.80 cm(2) at 45 minutes and 10.81 cm(2) at 75 minutes, as well as from 0.07 L/min at baseline to 0.09 L/min at 45 minutes and unchanged at 75 minutes, respectively. Sildenafil citrate elicited a significant effect on vertebral artery diameter, area and FVs.

Neurofibromatosis type 1 associated with vertebrobasilar dolichoectasia and pontine ischemic stroke.

PubMed

Giannantoni, Nadia Mariagrazia; Broccolini, Aldobrando; Frisullo, Giovanni; Pilato, Fabio; Profice, Paolo; Morosetti, Roberta; Di Lella, Giuseppe; Zampino, Giuseppe; Della Marca, Giacomo

2015-01-01

Neurofibromatosis type 1 (NF1) is a heterogeneous, common, neurocutaneous disorder presenting different complications during a life span, including cerebrovascular dysplasia. To our knowledge this is the first reported case of NF1 associated with vertebrobasilar dolichoectasia and pontine ischemic stroke. We describe a 57-year-old man with NF1 who presented an acute onset right-sided facial palsy and hemiplegia, dysarthria, and gait imbalance. Magnetic resonance imaging showed an acute left paramedian pontine infarct and a hypoplastic right vertebral artery. Brain Computed Tomography Angiography revealed the occurrence of vertebrobasilar dolichoectasia. Co-occurrence of VBD and NF1 might not be merely casual and it may significantly heighten the mortality rate in this multisystem disorder. We suggest a possible role of VBD in the genesis of our patient's clinical-radiological features and prompt the early detection of asymptomatic arteriopathy in individuals with NF1 in order to ameliorate patients' quality of life and life expectancy. Copyright © 2014 by the American Society of Neuroimaging.

Stenting versus aggressive medical therapy for intracranial arterial stenosis.

PubMed

Chimowitz, Marc I; Lynn, Michael J; Derdeyn, Colin P; Turan, Tanya N; Fiorella, David; Lane, Bethany F; Janis, L Scott; Lutsep, Helmi L; Barnwell, Stanley L; Waters, Michael F; Hoh, Brian L; Hourihane, J Maurice; Levy, Elad I; Alexandrov, Andrei V; Harrigan, Mark R; Chiu, David; Klucznik, Richard P; Clark, Joni M; McDougall, Cameron G; Johnson, Mark D; Pride, G Lee; Torbey, Michel T; Zaidat, Osama O; Rumboldt, Zoran; Cloft, Harry J

2011-09-15

Atherosclerotic intracranial arterial stenosis is an important cause of stroke that is increasingly being treated with percutaneous transluminal angioplasty and stenting (PTAS) to prevent recurrent stroke. However, PTAS has not been compared with medical management in a randomized trial. We randomly assigned patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70 to 99% of the diameter of a major intracranial artery to aggressive medical management alone or aggressive medical management plus PTAS with the use of the Wingspan stent system. The primary end point was stroke or death within 30 days after enrollment or after a revascularization procedure for the qualifying lesion during the follow-up period or stroke in the territory of the qualifying artery beyond 30 days. Enrollment was stopped after 451 patients underwent randomization, because the 30-day rate of stroke or death was 14.7% in the PTAS group (nonfatal stroke, 12.5%; fatal stroke, 2.2%) and 5.8% in the medical-management group (nonfatal stroke, 5.3%; non-stroke-related death, 0.4%) (P=0.002). Beyond 30 days, stroke in the same territory occurred in 13 patients in each group. Currently, the mean duration of follow-up, which is ongoing, is 11.9 months. The probability of the occurrence of a primary end-point event over time differed significantly between the two treatment groups (P=0.009), with 1-year rates of the primary end point of 20.0% in the PTAS group and 12.2% in the medical-management group. In patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS with the use of the Wingspan stent system, both because the risk of early stroke after PTAS was high and because the risk of stroke with aggressive medical therapy alone was lower than expected. (Funded by the National Institute of Neurological Disorders and Stroke and others; SAMMPRIS ClinicalTrials.gov number, NCT00576693.).

Location of the internal carotid artery and ophthalmic artery segments for non-invasive intracranial pressure measurement by multi-depth TCD.

PubMed

Hamarat, Yasin; Deimantavicius, Mantas; Kalvaitis, Evaldas; Siaudvytyte, Lina; Januleviciene, Ingrida; Zakelis, Rolandas; Bartusis, Laimonas

2017-12-01

The aim of the present study was to locate the ophthalmic artery by using the edge of the internal carotid artery (ICA) as the reference depth to perform a reliable non-invasive intracranial pressure measurement via a multi-depth transcranial Doppler device and to then determine the positions and angles of an ultrasonic transducer (UT) on the closed eyelid in the case of located segments. High tension glaucoma (HTG) patients and healthy volunteers (HVs) undergoing non-invasive intracranial pressure measurement were selected for this prospective study. The depth of the edge of the ICA was identified, followed by a selection of the depths of the IOA and EOA segments. The positions and angles of the UT on the closed eyelid were measured. The mean depth of the identified ICA edge for HTG patients was 64.3 mm and was 63.0 mm for HVs (p = 0.21). The mean depth of the selected IOA segment for HTG patients was 59.2 mm and 59.3 mm for HVs (p = 0.91). The mean depth of the selected EOA segment for HTG patients was 48.5 mm and 49.8 mm for HVs (p = 0.14). The difference in the located depths of the segments between groups was not statistically significant. The results showed a significant difference in the measured UT angles in the case of the identified edge of the ICA and selected ophthalmic artery segments (p = 0.0002). We demonstrated that locating the IOA and EOA segments can be achieved using the edge of the ICA as a reference point. OA: ophthalmic artery; IOA: intracranial segments of the ophthalmic artery; EOA: extracranial segments of the ophthalmic artery; ICA: internal carotid artery; UT: ultrasonic transducer; HTG: high tension glaucoma; SD: standard deviation; ICP: intracranial pressure; TCD: transcranial Doppler.

Is fetal-type posterior cerebral artery a risk factor for intracranial aneurysm as analyzed by multislice CT angiography?

PubMed

He, Zhen; Wan, Yeda

2018-01-01

Fetal-type posterior cerebral artery (FTP) is a common anatomic variation that is closely associated with intracranial aneurysm. In the present study, multislice computed tomography angiography (CTA) was performed to assess whether FTP is a risk factor for intracranial aneurysm. CTA data of 364 consecutive cases of patients who were suspected with cerebrovascular disease or intracranial aneurysm of intracranial artery from 2013 to 2016 were reviewed and the incidence rates of FTP, other variations of the circle of Willis, intracranial aneurysm and FTP with intracranial aneurysm were evaluated. The χ 2 test was used to assess the influence of FTP and gender on the incidence rates of other variations of the circle of Willis, intracranial aneurysm and internal carotid artery-posterior communicating artery (ICA-PComA) aneurysm. Binary logistic regression analysis was performed to assess the associations of FTP and gender with intracranial aneurysm and ICA-PComA aneurysm. Compared with non-FTP patients, FTP cases exhibited significantly higher rates of other variations of the circle of Willis (χ 2 =80.173, P<0.001) and ICA-PComA aneurysm (χ 2 =4.437, P=0.035). Among patients with FTP and bilateral FTP, more female than male patients with intracranial aneurysm were identified. However, among all patients with intracranial aneurysm, no statistically significant differences in the prevalence of FTP (χ 2 =2.577, P=0.108) and bilateral FTP (χ 2 =2.199, P=0.159) between males and females were identified. Binary logistic regression analysis revealed that FTP and gender were risk factors for intracranial aneurysm and ICA-PComA aneurysm. A moderate association between FTP and ICA-PComA aneurysm (OR=2.762) were identified, although there was a weak association between FTP and intracranial aneurysm [odds ratio (OR)=1.365]. Furthermore, a strong association was identified between gender and intracranial aneurysm (OR=0.328), and a moderate association existed between gender and

Is fetal-type posterior cerebral artery a risk factor for intracranial aneurysm as analyzed by multislice CT angiography?

PubMed Central

He, Zhen; Wan, Yeda

2018-01-01

Fetal-type posterior cerebral artery (FTP) is a common anatomic variation that is closely associated with intracranial aneurysm. In the present study, multislice computed tomography angiography (CTA) was performed to assess whether FTP is a risk factor for intracranial aneurysm. CTA data of 364 consecutive cases of patients who were suspected with cerebrovascular disease or intracranial aneurysm of intracranial artery from 2013 to 2016 were reviewed and the incidence rates of FTP, other variations of the circle of Willis, intracranial aneurysm and FTP with intracranial aneurysm were evaluated. The χ2 test was used to assess the influence of FTP and gender on the incidence rates of other variations of the circle of Willis, intracranial aneurysm and internal carotid artery-posterior communicating artery (ICA-PComA) aneurysm. Binary logistic regression analysis was performed to assess the associations of FTP and gender with intracranial aneurysm and ICA-PComA aneurysm. Compared with non-FTP patients, FTP cases exhibited significantly higher rates of other variations of the circle of Willis (χ2=80.173, P<0.001) and ICA-PComA aneurysm (χ2=4.437, P=0.035). Among patients with FTP and bilateral FTP, more female than male patients with intracranial aneurysm were identified. However, among all patients with intracranial aneurysm, no statistically significant differences in the prevalence of FTP (χ2=2.577, P=0.108) and bilateral FTP (χ2=2.199, P=0.159) between males and females were identified. Binary logistic regression analysis revealed that FTP and gender were risk factors for intracranial aneurysm and ICA-PComA aneurysm. A moderate association between FTP and ICA-PComA aneurysm (OR=2.762) were identified, although there was a weak association between FTP and intracranial aneurysm [odds ratio (OR)=1.365]. Furthermore, a strong association was identified between gender and intracranial aneurysm (OR=0.328), and a moderate association existed between gender and ICA

Evaluation of the Effects of Sildenafil Citrate (Viagra) on Vertebral Artery Blood Flow in Patients with Vertebro-Basilar Insufficiency

PubMed Central

Berilgen, Sait; Ozdemir, Huseyin; Tekatas, Aslan; Ogur, Erkin

2008-01-01

Objective To investigate the effects of sildenafil citrate (Viagra) on the vertebral artery blood flow of patients with vertebro-basilar insufficiency (VBI) using color duplex sonography (CDS). Materials and Methods The study included 21 patients with VBI (aged 31-76; mean 61.0 ± 10.5 yrs). We administered a 50 mg oral dose of sildenafil citrate to all patients. Next, we measured the peak systolic velocity (Vmax), end diastolic velocity (Vmin), resistive index (RI), pulsatility index (PI), diameter, area, and flow volume (FV) of vertebral arteries using CDS before the administration of sildenafil citrate; 45 minutes after, and 75 minutes after administration. Statistical testing was performed using SPSS for windows version 11.0. The statistical test used to determine the outcome of the analysis was the repeated measures analysis of variance (ANOVA) test. Results Compared to the baseline values, the vertebral artery diameter, area, and FV increased significantly following the administration of sildenafil citrate. The diameter, area and FV increased from 3.39 mm at 45 minutes to 3.64 mm at 75 minutes, 9.43 cm2 to 10.80 cm2 at 45 minutes and 10.81 cm2 at 75 minutes, as well as from 0.07 L/min at baseline to 0.09 L/min at 45 minutes and unchanged at 75 minutes, respectively. Conclusion Sildenafil citrate elicited a significant effect on vertebral artery diameter, area and FVs. PMID:19039262

Stroke Caused by Atherosclerosis of the Major Intracranial Arteries

PubMed Central

Banerjee, Chirantan; Chimowitz, Marc I.

2017-01-01

Our goal in this review is to discuss the pathophysiology, diagnosis and treatment of stroke caused by atherosclerosis of the major intracranial arteries. References for the review were identified by searching PubMed for related studies published from 1955 to June 2016 using search terms “intracranial stenosis” and “intracranial atherosclerosis”. Reference sections of published randomized clinical trials and previously published reviews were searched for additional references. Intracranial atherosclerotic disease (ICAD) is a highly prevalent cause of stroke that is associated with a high risk of recurrent stroke. It is more prevalent among blacks, Hispanics and Asians compared with whites. Diabetes, hypertension, metabolic syndrome, smoking, hyperlipidemia and a sedentary lifestyle are the major modifiable risk factors associated with ICAD. Randomized clinical trials comparing aggressive management (dual antiplatelet treatment for 90 days followed by aspirin monotherapy and intensive management of vascular risk factors) with intracranial stenting plus aggressive medical management have shown medical management alone to be safer and more effective for preventing stroke. As such, aggressive medical management has become the standard of care for symptomatic patients with ICAD. Nevertheless, there are subgroups of patients who are still at high risk of stroke despite being treated with aggressive medical management. Future research should aim to establish clinical, serologic, and imaging biomarkers to identify high-risk patients, and clinical trials evaluating novel therapies should be focused on these patients. PMID:28154100

C-reactive protein predicts further ischemic events in first-ever transient ischemic attack or stroke patients with intracranial large-artery occlusive disease.

PubMed

Arenillas, Juan F; Alvarez-Sabín, José; Molina, Carlos A; Chacón, Pilar; Montaner, Joan; Rovira, Alex; Ibarra, Bernardo; Quintana, Manuel

2003-10-01

The role of inflammation in intracranial large-artery occlusive disease is unclear. We sought to investigate the relationship between high-sensitivity C-reactive protein (CRP) levels and the risk of further ischemic events in first-ever transient ischemic attack (TIA) or stroke patients with intracranial large-artery occlusive disease. Of a total of 127 consecutive first-ever TIA or ischemic stroke patients with intracranial stenoses detected by transcranial Doppler ultrasonography, 71 fulfilled all inclusion criteria, which included angiographic confirmation. Serum high-sensitivity CRP level was determined a minimum of 3 months after the qualifying event. Patients were followed up during 1 year after blood sampling. Thirteen patients (18.3%) with intracranial large-artery occlusive disease experienced an end point event: 9 cerebral ischemic events, 7 of which were attributable to intracranial large-artery occlusive disease, and 4 myocardial infarctions. Patients in the highest quintile of high-sensitivity CRP level had a significantly higher adjusted odds ratio for new events compared with those in the first quintile (odds ratio, 8.66; 95% CI, 1.39 to 53.84; P=0.01). A high-sensitivity CRP level above the receiver operating characteristic curve cutoff value of 1.41 mg/dL emerged as an independent predictor of new end point events (hazard ratio, 7.14; 95% CI, 1.77 to 28.73; P=0.005) and of further intracranial large-artery occlusive disease-related ischemic events (hazard ratio, 30.67; 95% CI, 3.6 to 255.5; P=0.0015), after adjustment for age, sex, and risk factors. Kaplan-Meier curves showed that a significantly lower proportion of patients with a high-sensitivity CRP >1.41 mg/dL remained free of a new ischemic event (P<0.0001). High-sensitivity CRP serum level predicts further intracranial large-artery occlusive disease-related and any major ischemic events in patients with first-ever TIA or stroke with intracranial large-artery occlusive disease. These findings

Obstructive hydrocephalus and facial nerve palsy secondary to vertebrobasilar dolichoectasia: Case Report

PubMed Central

Mohammed, Kazim; Iqbal, Javeed; Kamel, Hussein; Mathew, John; Al-Sulaiti, Ghanem

2018-01-01

Background: Symptomatic hydrocephalus due to vertebrobasilar dolichoectasia is a rare occurrence. Case Description: We report a patient who presented with acute confusion and vomiting. Neuroimaging revealed elongated and tortuous basilar artery indenting and elevating the floor of third ventricle causing obstructive hydrocephalus. Initially, the patient was treated with external ventricular drain and then with ventriculo-peritoneal shunt. Conclusion: We suggest prompt surgical intervention upon diagnosis as a first choice of treatment in order to avoid further complications. PMID:29629227

Prevalence of extracranial carotid artery aneurysms in patients with an intracranial aneurysm.

PubMed

Pourier, V E C; van Laarhoven, C J H C M; Vergouwen, M D I; Rinkel, G J E; de Borst, Gert J

2017-01-01

Aneurysms in various arterial beds have common risk- and genetic factors. Data on the correlation of extracranial carotid artery aneurysms (ECAA) with aneurysms in other vascular territories are lacking. We aimed to investigate the prevalence of ECAA in patients with an intracranial aneurysm (IA). We used prospectively collected databases of consecutive patients registered at the University Medical Center Utrecht with an unruptured intracranial aneurysm (UIA) or aneurysmal Subarachnoid hemorrhage (SAH). The medical files of patients included in both databases were screened for availability of radiological reports, imaging of the brain and of the cervical carotid arteries. All available radiological images were then reviewed primarily for the presence of an ECAA and secondarily for an extradural/cavernous carotid or vertebral artery aneurysm. An ECAA was defined as a fusiform dilation ≥150% of the normal internal or common carotid artery or a saccular distention of any size. We screened 4465 patient records (SAH database n = 3416, UIA database n = 1049), of which 2931 had radiological images of the carotid arteries available. An ECAA was identified in 12/638 patients (1.9%; 95% CI 1.1-3.3) with completely imaged carotid arteries and in 15/2293 patients (0.7%; 95% CI 0.4-1.1) with partially depicted carotid arteries. Seven out of 27 patients had an additional extradural (cavernous or vertebral artery) aneurysm. This comprehensive study suggests a prevalence for ECAA of approximately 2% of patients with an IA. The rarity of the disease makes screening unnecessary so far. Future registry studies should study the factors associated with IA and ECAA to estimate the prevalence of ECAA in these young patients more accurately.

Association between extra- and intracranial calcifications of the internal carotid artery: a CBCT imaging study.

PubMed

Damaskos, S; Aartman, I H A; Tsiklakis, K; van der Stelt, P; Berkhout, W E R

2015-01-01

This study aimed to evaluate the association between the extracranial and intracranial calcification depiction of the internal carotid artery (ICA), incidentally found in CBCT examinations in adults, and to discuss the conspicuous clinical implications. Out of a series of 1085 CBCT examinations, 705 CBCT scans were selected according to pre-defined criteria. The extra- and intracranial calcifications depicted along the course of the ICA were documented according to a comprehensive set of descriptive criteria. In total, 799 findings were detected, 60.1% (n = 480) were intracranially and 39.9% (n = 319) were extracranially allocated. The χ(2) test showed associations between all variables (p < 0.001). Also, most of the combinations of variables showed statistically significant results in the McNemar's test (p < 0.001). We found that a significant correlation exists between extra- and intracranial calcifications of the ICA. It is clear that in cases of the presence of a calcification in the ICA extracranially, the artery's intracranial portion has an increased risk of showing the same findings. CBCT imaging is widely used as a diagnostic tool, thus, our results contribute to the identification of a subgroup of patients who should undergo further medical evaluation of the atherosclerosis of the ICAs.

Prognosis of untreated strokes due to anterior circulation proximal intracranial arterial occlusions detected by use of computed tomography angiography.

PubMed

Lima, Fabricio O; Furie, Karen L; Silva, Gisele S; Lev, Michael H; Camargo, Erica C S; Singhal, Aneesh B; Harris, Gordon J; Halpern, Elkan F; Koroshetz, Walter J; Smith, Wade S; Nogueira, Raul G

2014-02-01

Limited data exist regarding the natural history of proximal intracranial arterial occlusions. OBJECTIVE To investigate the outcomes of patients who had an acute ischemic stroke attributed to an anterior circulation proximal intracranial arterial occlusion. A prospective cohort study at 2 university-based hospitals from 2003 to 2005 in which nonenhanced computed tomography scans and computed tomography angiograms were obtained at admission of all adult patients suspected of having an ischemic stroke in the first 24 hours of symptom onset. Anterior circulation proximal intracranial arterial occlusion. Frequency of good outcome (defined as a modified Rankin Scale score of ≤ 2) and mortality at 6 months. A total of 126 patients with a unilateral complete occlusion of the intracranial internal carotid artery (ICA; 26 patients: median National Institutes of Health Stroke Scale [NIHSS] score, 11 [interquartile range, 5-17]), of the M1 segment of the middle cerebral artery (MCA; 52 patients: median NIHSS score, 13 [interquartile range, 6-16]), or of the M2 segment of the MCA (48 patients: median NIHSS score, 7 [interquartile range, 4-15]) were included. Of these 3 groups of patients, 10 (38.5%), 20 (38.5%), and 26 (54.2%) with ICA, MCA-M1, and MCA-M2 occlusions, respectively, achieved a modified Rankin Scale score of 2 or less, and 6 (23.1%), 12 (23.1%), and 10 (20.8%) were dead at 6 months. Worse outcomes were seen in patients with a baseline NIHSS score of 10 or higher, with a modified Rankin Scale score of 2 or less achieved in only 7.1% (1 of 14), 23.5% (8 of 34), and 22.7% (5 of 22) of patients and mortality rates of 35.7% (5 of 14), 32.4% (11 of 34), and 40.9% (9 of 22) among patients with ICA, MCA-M1, and MCA-M2 occlusions, respectively. Age (odds ratio, 0.94 [95% CI, 0.91-0.98]), NIHSS score (odds ratio, 0.73 [95% CI, 0.64-0.83]), and strength of leptomeningeal collaterals (odds ratio, 2.37 [95% CI, 1.08-5.20]) were independently associated with outcome, whereas

Comparison of High-Resolution MR Imaging and Digital Subtraction Angiography for the Characterization and Diagnosis of Intracranial Artery Disease.

PubMed

Lee, N J; Chung, M S; Jung, S C; Kim, H S; Choi, C-G; Kim, S J; Lee, D H; Suh, D C; Kwon, S U; Kang, D-W; Kim, J S

2016-12-01

High-resolution MR imaging has recently been introduced as a promising diagnostic modality in intracranial artery disease. Our aim was to compare high-resolution MR imaging with digital subtraction angiography for the characterization and diagnosis of various intracranial artery diseases. Thirty-seven patients who had undergone both high-resolution MR imaging and DSA for intracranial artery disease were enrolled in our study (August 2011 to April 2014). The time interval between the high-resolution MR imaging and DSA was within 1 month. The degree of stenosis and the minimal luminal diameter were independently measured by 2 observers in both DSA and high-resolution MR imaging, and the results were compared. Two observers independently diagnosed intracranial artery diseases on DSA and high-resolution MR imaging. The time interval between the diagnoses on DSA and high-resolution MR imaging was 2 weeks. Interobserver diagnostic agreement for each technique and intermodality diagnostic agreement for each observer were acquired. High-resolution MR imaging showed moderate-to-excellent agreement (interclass correlation coefficient = 0.892-0.949; κ = 0.548-0.614) and significant correlations (R = 0.766-892) with DSA on the degree of stenosis and minimal luminal diameter. The interobserver diagnostic agreement was good for DSA (κ = 0.643) and excellent for high-resolution MR imaging (κ = 0.818). The intermodality diagnostic agreement was good (κ = 0.704) for observer 1 and moderate (κ = 0.579) for observer 2, respectively. High-resolution MR imaging may be an imaging method comparable with DSA for the characterization and diagnosis of various intracranial artery diseases. © 2016 by American Journal of Neuroradiology.

Infarcts presenting with a combination of medial medullary and posterior inferior cerebellar artery syndromes.

PubMed

Lee, Hyung; Baik, Seung Kug

2004-09-15

Cerebellar and medial medullary infarctions are well-known vertebrobasilar stroke syndromes. However, their development in a patient with distal vertebral artery occlusion has not been previously reported. A 49-year-old man with longstanding hypertension suddenly developed vertigo, right-sided Horner syndrome, and left-sided weakness. An MRI of the brain showed acute infarcts in the right inferior cerebellum (posterior inferior cerebellar artery territory) and the right upper medial medulla (direct penetrating branches of vertebral artery). Magnetic resonance angiogram showed occlusion of the distal vertebral artery on the right side. Atherothrombotic occlusion of the distal vertebral artery may cause this unusual combination of vertebrobasilar stroke.

Intracranial cerebral artery disease as a risk factor for central nervous system complications of coronary artery bypass graft surgery.

PubMed

Yoon, B W; Bae, H J; Kang, D W; Lee, S H; Hong, K S; Kim, K B; Park, B J; Roh, J K

2001-01-01

Although extracranial carotid artery disease (ECAD) is accepted as a risk factor for central nervous system (CNS) complications after coronary artery bypass graft (CABG) surgery, it remains to be clarified whether intracranial cerebral artery disease (ICAD) may also increase the risk. We conducted a prospective study to elucidate the relation between ICAD and CNS complications after CABG surgery. We prospectively studied 201 patients undergoing nonemergency isolated CABG surgery during a 39-month period (from March 1995 to June 1998). Each patient was evaluated before surgery with neurological examination, transcranial Doppler, and carotid duplex ultrasonography. Magnetic resonance angiography was used to determine the presence and severity of ECAD and ICAD in patients with abnormal findings on clinical examination, carotid duplex ultrasonography, or transcranial Doppler. Patients were followed after surgery and evaluated for the development of CNS complications. Association between CNS complications and their potential predictors was analyzed. One hundred nine patients (54.2%) were found to have ECAD and/or ICAD. ECAD alone was found in 48 patients (23.9%), ICAD alone in 33 (16.4%), and both ECAD and ICAD in 28 (13.9%). Fifty-one patients (25.4%) had single or multiple CNS complications: 23 (11.4%) had delirium; 18 (9.0%) had hypoxic-metabolic encephalopathy; 7 (3.5%) had stroke; and 7 (3. 5%) had seizure. In multivariate analysis, ICAD was found to have an independent association with the development of CNS complications (prevalence OR, 2.28; 95% CI, 1.04 to 5.01) after controlling for covariates including age, occurrence of intraoperative events, and reoperation. The joint effect of ECAD and ICAD was also statistically significant and stronger than ICAD alone (prevalence OR, 3.87; 95% CI, 1.80 to 6.52). Our results suggest that ICAD may be an independent risk factor for CNS complications after CABG surgery. These results support pre-CABG evaluation of the

Successful Treatment of Symptomatic Intracranial Carotid Artery Stenosis Using a 24-mm Long Bare Metal Coronary Stent.

PubMed

Rehman, Azeem A; Turner, Ryan C; Lucke-Wold, Brandon P; Boo, SoHyun

2017-06-01

Intracranial arterial atherosclerosis represents a common cause of stroke. Despite aggressive and optimal medical management, many patients will unfortunately suffer additional cerebrovascular events. The role of endovascular intervention for intracranial atherosclerotic disease continues to be uncertain, particularly in regard to extensive, symptomatic stenosis. We present a case of a 42-year-old man with a complex medical history who presented with recurrent ischemic stroke in the ipsilateral hemisphere despite optimal medical management. Given the length of stenosis and the luminal size of the intracranial cavernous and petrous segments of the internal carotid artery, we used a bare metal coronary stent (4.0 mm × 24 mm). This represents one of the longest stents deployed for intracranial disease reported in the literature. This case illustrates that a long coronary stent might be successfully used to manage extensive intracranial lesions. We also review the efficacy of using 1 very long stent versus multiple overlapping stents, with reference to the coronary angiography literature. Copyright © 2017 Elsevier Inc. All rights reserved.

CFD Modelling of Local Hemodynamics in Intracranial Aneurysms Harboring Arterial Branches.

PubMed

Krylov, Vladimir; Grigoryeva, Elena; Dolotova, Daria; Blagosklonova, Evgenia; Gavrilov, Andrey

2017-01-01

The main cause of non-traumatic subarachnoid haemorrhage is an intracranial aneurysm's rupture. The choice of treatment approach is exceptionally difficult in cases of aneurysms with additional branches on the aneurysm's dome or neck. The impact of the arterial branches on local hemodynamics is still unclear and controversial question. At the same time, up-to-date methods of image processing and mathematical modeling provide a way to investigate the hemodynamic environment of aneurysms. The paper discusses hemodynamic aspects of aneurysms harboring arterial branch through the use of patient-specific 3D models and computational fluid dynamics (CFD) methods. The analysis showed that the presence of the arterial branches has a great influence on flow streamlines and wall shear stress, particularly for side wall aneurysm.

Critical cerebral perfusion pressure at high intracranial pressure measured by induced cerebrovascular and intracranial pressure reactivity.

PubMed

Bragin, Denis E; Statom, Gloria L; Yonas, Howard; Dai, Xingping; Nemoto, Edwin M

2014-12-01

The lower limit of cerebral blood flow autoregulation is the critical cerebral perfusion pressure at which cerebral blood flow begins to fall. It is important that cerebral perfusion pressure be maintained above this level to ensure adequate cerebral blood flow, especially in patients with high intracranial pressure. However, the critical cerebral perfusion pressure of 50 mm Hg, obtained by decreasing mean arterial pressure, differs from the value of 30 mm Hg, obtained by increasing intracranial pressure, which we previously showed was due to microvascular shunt flow maintenance of a falsely high cerebral blood flow. The present study shows that the critical cerebral perfusion pressure, measured by increasing intracranial pressure to decrease cerebral perfusion pressure, is inaccurate but accurately determined by dopamine-induced dynamic intracranial pressure reactivity and cerebrovascular reactivity. Cerebral perfusion pressure was decreased either by increasing intracranial pressure or decreasing mean arterial pressure and the critical cerebral perfusion pressure by both methods compared. Cortical Doppler flux, intracranial pressure, and mean arterial pressure were monitored throughout the study. At each cerebral perfusion pressure, we measured microvascular RBC flow velocity, blood-brain barrier integrity (transcapillary dye extravasation), and tissue oxygenation (reduced nicotinamide adenine dinucleotide) in the cerebral cortex of rats using in vivo two-photon laser scanning microscopy. University laboratory. Male Sprague-Dawley rats. At each cerebral perfusion pressure, dopamine-induced arterial pressure transients (~10 mm Hg, ~45 s duration) were used to measure induced intracranial pressure reactivity (Δ intracranial pressure/Δ mean arterial pressure) and induced cerebrovascular reactivity (Δ cerebral blood flow/Δ mean arterial pressure). At a normal cerebral perfusion pressure of 70 mm Hg, 10 mm Hg mean arterial pressure pulses had no effect on

Limb-shaking transient ischemic attack masquerading as lumbar radiculopathy from pericallosal artery stenosis treated successfully with intracranial angioplasty and stenting.

PubMed

Kalia, Junaid; Wolfe, Thomas; Zaidat, Osama O

2010-03-01

The pericallosal artery is rarely associated with intracranial atherosclerotic disease and, until recently, was usually not amenable to endovascular therapy with balloon angioplasty and stenting. We present an elderly patient with postural left leg-shaking episodes secondary to pericallosal artery stenosis, which was treated initially with primary intracranial balloon angioplasty, and subsequently, angioplasty and stenting as a result of recurrent stenosis. Both procedures were preformed without complications, and the patient remained free of symptoms on 6-month follow-up. This case demonstrates unique clinical and neuroendovascular aspects; the isolated postural leg-shaking transient ischemic attacks, initially mistaken for radiculopathy and local joint etiology, were found later to be cerebrovascular ischemic in origin. Moreover, the correlation between the findings of computed tomography perfusion and angiography localized the lesion into the medial frontal lobe and pericallosal artery territory. In addition, the technical aspect provides insight into the current state of neuroendovascular techniques, addressing the difficulty of access into very small and distal intracranial arteries affected by stenosis. Copyright 2010 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Planning-free cerebral blood flow territory mapping in patients with intracranial arterial stenosis

PubMed Central

Arteaga, Daniel F; Strother, Megan K; Davis, L Taylor; Fusco, Matthew R; Faraco, Carlos C; Roach, Brent A; Scott, Allison O

2016-01-01

A noninvasive method for quantifying cerebral blood flow and simultaneously visualizing cerebral blood flow territories is vessel-encoded pseudocontinuous arterial spin labeling MRI. However, obstacles to acquiring such information include limited access to the methodology in clinical centers and limited work on how clinically acquired vessel-encoded pseudocontinuous arterial spin labeling data correlate with gold-standard methods. The purpose of this work is to develop and validate a semiautomated pipeline for the online quantification of cerebral blood flow maps and cerebral blood flow territories from planning-free vessel-encoded pseudocontinuous arterial spin labeling MRI with gold-standard digital subtraction angiography. Healthy controls (n = 10) and intracranial atherosclerotic disease patients (n = 34) underwent 3.0 T MRI imaging including vascular (MR angiography) and hemodynamic (cerebral blood flow-weighted arterial spin labeling) MRI. Patients additionally underwent catheter and/or CT angiography. Variations in cross-territorial filling were grouped according to diameters of circle of Willis vessels in controls. In patients, Cohen’s k-statistics were computed to quantify agreement in perfusion patterns between vessel-encoded pseudocontinuous arterial spin labeling and angiography. Cross-territorial filling patterns were consistent with circle of Willis anatomy. The intraobserver Cohen's k-statistics for cerebral blood flow territory and digital subtraction angiography perfusion agreement were 0.730 (95% CI = 0.593–0.867; reader one) and 0.708 (95% CI = 0.561–0.855; reader two). These results support the feasibility of a semiautomated pipeline for evaluating major neurovascular cerebral blood flow territories in patients with intracranial atherosclerotic disease. PMID:27389177

Acute Stroke and Obstruction of the Extracranial Carotid Artery Combined with Intracranial Tandem Occlusion: Results of Interventional Revascularization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lescher, Stephanie, E-mail: stephanie.lescher@kgu.de; Czeppan, Katja; Porto, Luciana

PurposeDue to high thrombus load, acute stroke patients with tandem obstructions of the extra- and intracranial carotid arteries or the middle cerebral artery show a very limited response to systemic thrombolysis. Interventional treatment with mechanical thrombectomy—often in combination with acute stenting of underlying atherosclerotic stenosis or dissection—is increasingly used. It has been shown that such complex interventions are technically feasible. The lack of optimal management strategies and clinical data encouraged us to review our acute stroke interventions in patient with anterior circulation tandem lesions to determine lesion patterns, interventional approaches, and angiographic or clinical outcomes.Patients and MethodsWe retrospectively analyzed amore » series of 39 consecutive patients with intracranial vessel occlusion of the anterior circulation simultaneously presenting with high-grade cervical internal carotid artery (ICA) stenosis or occlusion.ResultsEmergency ICA stent implantation was technically feasible in all patients, and intracranial recanalization with TICI ≥ 2b was reached in a large number of patients (64 %). Good clinical outcomes (mRS ≤ 2 at 3 months) were achieved in one third of the patients (36 %). Symptomatic hemorrhages occurred in four patients (10 %). Mortality was 10 %.ConclusionEndovascular recanalization of acute cervical carotid artery occlusion was technically feasible in all patients, and resulted in high extra- and intracranial revascularization rates. A trend for favorable clinical outcome was seen in a higher TICI score, younger age, good collateral status, and combined IV rTPA and endovascular therapy.« less

Doppler sonography characteristics of vertebrobasilar circulation in patients with Parkinson's disease.

PubMed

Vidović, Mirjana; Sinanović, Osman; Smajlović, Dzevdet; Burina, Adnan; Hudić, Josip

2008-08-01

The objective of the study was to analyze the doppler sonography findings of vertebrobasilar circulation (VB) in patients with Parkinson's disease. 40 patients were analyzed (25 men's and 15 women) with Parkinson's disease, average age was 61.9 years (SD=11.43), treated at the Clinic for Neurology in Tuzla. Device for doppler sonography was Multidop x 4. Doppler sonography findings of VB circulation were analyzed in order to computerized tomography (CT) findings of the brain (with or without ischemic lacunar lesions) and in order to presence of postural disturbances as one of dominant Parkinson's disease symptoms during actual hospitalization. Our results suggest that vertebrobasilar insufficiency is more frequent in patients with Parkinson's disease (no matter of type) and postural disturbances as a dominant symptom comparing to group of Parkinson's disease patients without postural disturbances. These results implicate the importance of doppler sonography findings of vertebrobasilar circulation in patients with Parkinson's disease and possibility of considering role of vertebrobasilar insufficiency in development of postural disturbances.

Extra- and intra-cranial arterial calcifications in adults depicted as incidental findings on cone beam CT images.

PubMed

Damaskos, Spyros; Tsiklakis, Kostas; Syriopoulos, Kostas; van der Stelt, Paul

2015-04-01

The aim of this study was to evaluate, retrospectively, the gender- and age-related prevalence of incidentally found calcifications, depicted within the course of the extra- and intra-cranial portion of internal carotid artery (ICA), in cone beam computed tomography (CBCT) examinations in adults, and to assess their clinical significance. Out of a pull of 700 CBCT examinations a total of 484 CBCT scans of adult patients were finally selected according to a set of pre-defined criteria. These were evaluated for arterial calcifications presence within the ICAs course according to gender and age criteria. In total, 492 calcifications were detected: 211 (42.88%) extra-cranial and 281 (57.11%) intra-cranial. Those were recorded in 150 scans (30.99%) and 161 scans (33.26%), respectively. Calcifications, with either extra- or intra-cranial allocation, were found more frequent in males than in females (all p-values < 0.05); also patients who presented with positive findings were older than those without findings (all p-values < 0.05). Furthermore, calcification presence with either extra- or intra-cranial allocation increases with age (all p-values < 0.05). Significant calcification frequencies were found within the ICA's course, in CBCT scans. Moreover, an increased incidence of either extra- or intra-cranial presence of these depictions and its relation to age and gender was documented.

Familial intracranial aneurysms: is anatomic vulnerability heritable?

PubMed

Mackey, Jason; Brown, Robert D; Moomaw, Charles J; Hornung, Richard; Sauerbeck, Laura; Woo, Daniel; Foroud, Tatiana; Gandhi, Dheeraj; Kleindorfer, Dawn; Flaherty, Matthew L; Meissner, Irene; Anderson, Craig; Rouleau, Guy; Connolly, E Sander; Deka, Ranjan; Koller, Daniel L; Abruzzo, Todd; Huston, John; Broderick, Joseph P

2013-01-01

Previous studies have suggested that family members with intracranial aneurysms (IAs) often harbor IAs in similar anatomic locations. IA location is important because of its association with rupture. We tested the hypothesis that anatomic susceptibility to IA location exists using a family-based IA study. We identified all affected probands and first-degree relatives (FDRs) with a definite or probable phenotype in each family. We stratified each IA of the probands by major arterial territory and calculated each family's proband-FDR territory concordance and overall contribution to the concordance analysis. We then matched each family unit to an unrelated family unit selected randomly with replacement and performed 1001 simulations. The median concordance proportions, odds ratios (ORs), and P values from the 1001 logistic regression analyses were used to represent the final results of the analysis. There were 323 family units available for analysis, including 323 probands and 448 FDRs, with a total of 1176 IAs. IA territorial concordance was higher in the internal carotid artery (55.4% versus 45.6%; OR, 1.54 [1.04-2.27]; P=0.032), middle cerebral artery (45.8% versus 30.5%; OR, 1.99 [1.22-3.22]; P=0.006), and vertebrobasilar system (26.6% versus 11.3%; OR, 2.90 [1.05-8.24], P=0.04) distributions in the true family compared with the comparison family. Concordance was also higher when any location was considered (53.0% versus 40.7%; OR, 1.82 [1.34-2.46]; P<0.001). In a highly enriched sample with familial predisposition to IA development, we found that IA territorial concordance was higher when probands were compared with their own affected FDRs than with comparison FDRs, which suggests that anatomic vulnerability to IA formation exists. Future studies of IA genetics should consider stratifying cases by IA location.

Intracranial arterial stenosis.

PubMed

Carvalho, Marta; Oliveira, Ana; Azevedo, Elsa; Bastos-Leite, António J

2014-04-01

Intracranial arterial stenosis (IAS) is usually attributable to atherosclerosis and corresponds to the most common cause of stroke worldwide. It is very prevalent among African, Asian, and Hispanic populations. Advancing age, systolic hypertension, diabetes mellitus, high levels of low-density lipoprotein cholesterol, and metabolic syndrome are some of its major risk factors. IAS may be associated with transient or definite neurological symptoms or can be clinically asymptomatic. Transcranial Doppler and magnetic resonance angiography are the most frequently used ancillary examinations for screening and follow-up. Computed tomography angiography can either serve as a screening tool for the detection of IAS or increasingly as a confirmatory test approaching the diagnostic accuracy of catheter digital subtraction angiography, which is still considered the gold (confirmation) standard. The risk of stroke in patients with asymptomatic atherosclerotic IAS is low (up to 6% over a mean follow-up period of approximately 2 years), but the annual risk of stroke recurrence in the presence of a symptomatic stenosis may exceed 20% when the degree of luminal narrowing is 70% or more, recently after an ischemic event, and in women. It is a matter of controversy whether there is a specific type of treatment other than medical management (including aggressive control of vascular risk factors and antiplatelet therapy) that may alter the high risk of stroke recurrence among patients with symptomatic IAS. Endovascular treatment has been thought to be helpful in patients who fail to respond to medical treatment alone, but recent data contradict such expectation. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Preferential location for arterial dissection presenting as golf-related stroke.

PubMed

Choi, M H; Hong, J M; Lee, J S; Shin, D H; Choi, H A; Lee, K

2014-02-01

Golf-related stroke has not been systematically reviewed. The purpose of our study was to describe in detail this particular stroke syndrome. Seven patients were analyzed at a university hospital and 7 patients were reviewed from MEDLINE literature. General demographics, symptom onset, neurologic signs, radiologic findings, and outcome were investigated. A total of 14 patients including 7 patients from the MEDLINE search were analyzed; all were men, with a mean age of 46.9 ± 12.8 years. Symptom onset was classified as during the golf swing (n = 9), unknown (n = 3), and after playing golf (n = 2). Most patients (n = 12) showed involvement of the vertebral artery and 2 patients showed involvement of the internal carotid artery (P = .008). Nine dissections were found on the right side, 3 on the left side, and 2 were bilateral (P = .046). Twelve patients had extracranial involvement and 2 patients had intracranial involvement (P = .008). Seven patients returned to normal, 5 returned to independence, 1 had unknown status, and 1 died. The anatomic preference of golf-related craniocervical arterial dissection is associated with the extracranial and vertebrobasilar system with a right-sided tendency as the result of stereotypical rotational movement during a golf swing.

Characteristics of intracranial aneurysms associated with extracranial carotid artery disease in South Korea.

PubMed

Cho, Young Dae; Jung, Keun-Hwa; Roh, Jae-Kyu; Kang, Hyun-Seung; Han, Moon Hee; Lim, Jeong Wook

2013-09-01

Although it is hypothesized that inflammatory signals and/or hemodynamic stress resulting from carotid disease increase the risk of aneurysm formation and growth, a relationship between intracranial aneurysms and extracranial carotid artery disease (ECAD) has not been explored. Here, we examined the characteristics of intracranial aneurysms associated with ECAD. A total of 606 consecutive patients with stenosis of 50% or more of the proximal internal carotid artery (pICA) were enrolled. Stenosis was identified by conventional angiography between January 2003 and December 2009. We determined the prevalence of intracranial aneurysms in this population. The characteristics of the aneurysms were analyzed according to the degree and laterality of stenosis. The changes in the aneurysms were tracked for the evaluation of stability. In 86 patients (14.2%), 120 aneurysms were detected in association with pICA stenosis. In this group, 97 were associated with unilateral pICA stenosis. The distribution of aneurysms was independent of the laterality of stenosis, but aneurysms were more prevalent in the contralateral side as the stenosis grade increased (P<0.001). All aneurysms with an imaging follow-up (28.9 ± 14.3 months) were stable, and the course was not affected by treatment of the carotid stenosis. In 23 aneurysms associated with bilateral pICA stenosis, there was only one case that increased in size during a 41-month period. Intracranial aneurysms were most likely associated with ECAD, but were evenly distributed irrespective of the laterality of the stenosis. The distribution was related to the severity of the contralateral pICA stenosis. The low incidence of aneurysm growth or rupture in patients with significant ECAD indicates that these aneurysms do not require immediate intervention more than other conditions. Copyright © 2013 Elsevier B.V. All rights reserved.

Dolichoectatic aneurysms of the vertebrobasilar system: clinical and radiographic factors that predict poor outcomes.

PubMed

Xu, David S; Levitt, Michael R; Kalani, M Yashar S; Rangel-Castilla, Leonardo; Mulholland, Celene B; Abecassis, Isaac J; Morton, Ryan P; Nerva, John D; Siddiqui, Adnan H; Levy, Elad I; Spetzler, Robert F; Albuquerque, Felipe C; McDougall, Cameron G

2018-02-01

OBJECTIVE Fusiform dolichoectatic vertebrobasilar aneurysms are rare, challenging lesions. The natural history of these lesions and medium- and long-term patient outcomes are poorly understood. The authors sought to evaluate patient prognosis after diagnosis of fusiform dolichoectatic vertebrobasilar aneurysms and to identify clinical and radiographic predictors of neurological deterioration. METHODS The authors reviewed multiple, prospectively maintained, single-provider databases at 3 large-volume cerebrovascular centers to obtain data on patients with unruptured, fusiform, basilar artery dolichoectatic aneurysms diagnosed between January 1, 2000, and January 1, 2015. RESULTS A total of 50 patients (33 men, 17 women) were identified; mean clinical follow-up was 50.1 months and mean radiographic follow-up was 32.4 months. At last follow-up, 42% (n = 21) of aneurysms had progressed and 44% (n = 22) of patients had deterioration of their modified Rankin Scale scores. When patients were dichotomized into 2 groups- those who worsened and those who did not-univariate analysis showed 5 variables to be statistically significantly different: sex (p = 0.007), radiographic brainstem compression (p = 0.03), clinical posterior fossa compression (p < 0.001), aneurysmal growth on subsequent imaging (p = 0.001), and surgical therapy (p = 0.006). A binary logistic regression was then created to evaluate these variables. The only variable found to be a statistically significant predictor of clinical worsening was clinical symptoms of posterior fossa compression at presentation (p = 0.01). CONCLUSIONS Fusiform dolichoectatic vertebrobasilar aneurysms carry a poor prognosis, with approximately one-half of the patients deteriorating or experiencing progression of their aneurysm within 5 years. Despite being high risk, intervention-when carefully timed (before neurological decline)-may be beneficial in select patients.

Coiling of a Ruptured Large Internal Carotid Artery Aneurysm via Extracranial-Intracranial Saphenous Vein Bypass Graft Just After Proximal Ligation of the Internal Carotid Artery.

PubMed

Tajima, Hayato; Araki, Yoshio; Izumi, Takashi; Nishihori, Masahiro; Okamoto, Sho; Wakabayashi, Toshihiko

2017-02-01

Combined direct and endovascular surgery has been performed to treat large to giant internal carotid artery (ICA) aneurysms. This report describes successful treatment of a large ICA aneurysm by coiling of the aneurysm via an extracranial-intracranial saphenous vein (SV) graft just after bypass and ICA proximal ligation. A 66-year-old woman presented with a left ICA supraclinoid aneurysm with progressive visual field defect and impaired visual acuity in the left eye. While waiting for scheduled surgery, she experienced a subarachnoid hemorrhage. An extracranial-intracranial high-flow bypass using an SV graft and proximal ligation of the ICA were performed. Coiling of the aneurysm was immediately performed successfully via the SV bypass graft. The patient experienced no new neurologic deficit after this treatment. Follow-up radiologic evaluations using magnetic resonance imaging and magnetic resonance angiography revealed complete aneurysm occlusion. Aneurysm coiling via an extracranial-intracranial SV bypass graft could offer an alternative when an antegrade access route to the ICA is not used because of prior parent artery ligation. Copyright © 2016 Elsevier Inc. All rights reserved.

Postural Effects on Intracranial Pressure as Assessed Noninvasively

NASA Technical Reports Server (NTRS)

Ueno, Toshiaki; Hargens, Alan R.; Ballard, R. E.; Shuer, L. M.; Cantrell, J. H.; Yost, W. T.; Holton, Emily M. (Technical Monitor)

1997-01-01

This study was designed to investigate effects of whole body tilting on intracranial compliance and pressure in six healthy volunteers by using a noninvasive ultrasonic device. Subjects were randomly tilted up or down sequentially at 60 degree, 30 degree head-up, supine, and 15 degree head-down position for one minute at each angle. We measured arterial blood pressure with a finger pressure cuff and changes in intracranial distance with an ultrasonic device. The device measures skull movement on the order of micro-meter. Our ultrasound technique demonstrates that skull movement is highly correlated (r$(circumflex){2}$=0.77) with intracranial pressure variations due to cerebral arterial pulsation. The amplitudes of arterial pressure (r$(circumflex){2}$=0.99 and those of intracranial distance changes (r$(circumflex){2}$=0.87) associated with one cardiac cycle were inversely correlated with the angle of tilt. The ratio of pulsation amplitudes for intracranial distance over arterial pressure also showed a significant increase as the angle of tilt was lowered (p=0.003). Thus, postural changes alter intracranial compliance in healthy volunteers and intracranial volume-buffering capacity is reduced in head-down position.

Microvascular decompression for hemifacial spasm secondary to vertebrobasilar dolichoectasia: surgical strategies, technical nuances and clinical outcomes.

PubMed

Zaidi, Hasan A; Awad, Al-Wala; Chowdhry, Shakeel A; Fusco, David; Nakaji, Peter; Spetzler, Robert F

2015-01-01

Hemifacial spasm (HFS) due to direct compression of the facial nerve by a dolichoectatic vertebrobasilar artery is rare. Vessels are often non-compliant and tethered by critical brainstem perforators. We set out to determine surgical strategies and outcomes for this challenging disease. All patients undergoing surgery for HFS secondary to vertebrobasilar dolichoectasia were reviewed. Hospital records, clinic notes and radiographic imaging were collected for outcome measures. Seventeen patients (eight males, nine females) were identified. Sixteen patients (94%) were treated with Teflon pledgets (DuPont, Wilmington, DE, USA) and one (6%) patient had a vascular sling placed around a severely diseased vertebral artery. All patients had significant reduction in symptoms and 82% of patients had complete resolution of symptoms (average follow-up: 41.4 months). One patient suffered persistent facial nerve paresis and swallowing difficulty. Two other patients suffered a 1 point decrease in the House-Brackmann facial nerve grading scale. Four patients (23%) required re-operation (infection, cerebrospinal fluid leak, and two patients with delayed recurrence of HFS). Of the latter, one patient required repositioning of a Teflon pledget and another patient underwent a sling decompression. There were no perioperative strokes or death. Excellent relief of symptoms with acceptable preoperative morbidity can be achieved using Teflon pledgets alone in most cases. In recalcitrant cases, sling transposition can be used to further augment the decompression. Careful attention must be paid to prevent vascular kinking and preserve brainstem perforators. Copyright © 2014 Elsevier Ltd. All rights reserved.

Imaging characteristics and pathogenesis of intracranial artery stenosis in patients with acute cerebral infarction

PubMed Central

Xu, Wenyuan; Xie, Ning; Zhang, Cheng; Huang, Qin

2018-01-01

The current study aimed to investigate the imaging characteristics and pathogenesis of intracranial artery stenosis in patients with acute cerebral infarction. In total, 84 patients diagnosed with acute cerebral infarction were recruited. Magnetic resonance angiography was performed to detect the existence of intracranial artery stenosis or occlusion. In addition, magnetic resonance imaging and diffusion weighted imaging were employed to analyze the infarction types and characteristics. In the majority of patients, the infarction resulted from internal carotid stenosis (77 cases; 91.7%), while it was caused by vertebral artery stenosis in a small number of cases (7 cases; 8.3%). Multiple infarction was identified the most common type of infarction among all cases (69.0%). The most common types of infarctions in the internal carotid system were multiple infarction implicating both the cortex and centrum ovale (23.4%), and internal watershed infarction (22.1%). Although the number of cases was relatively small, multiple infarction was observed to have a high incidence in the vertebral artery system. Bedside electrocardiogram was also recorded to determine the sinus rhythm and examine the abnormal hemodynamics. The sinus bradycardia rate of patients with multiple infarction was markedly greater in comparison with that in single infarction patients (χ2=0.01, P<0.05). Transcranial Doppler plus microembolus monitoring was utilized to explore the possible pathogenesis of all types of infarctions, such as arterial embolization. As compared with the single infarction patients, the embolus rate in patients with multiple infarction was notably increased by ~3.7-fold (χ2=8.65, P<0.05). In conclusion, the cerebral infarction was common in the internal carotid system, with multiple infarction observed in the majority of cases. The pathogenesis of cerebral infarction included arterial embolization and inadequate hemoperfusion. PMID:29725389

Relationship between intracranial internal carotid artery calcification and enlarged cerebral perivascular space.

PubMed

Tao, Xiao-Xiao; Li, Ge-Fei; Wu, Yi-Lan; Liu, Yi-Sheng; Zhao, Ying; Shi, Yan-Hui; Zhuang, Mei-Ting; Hou, Tian-Yu; Zhao, Rong; Liu, Feng-Di; Wang, Xue-Mei; Shen, Ying; Cui, Guo-Hong; Su, Jing-Jing; Chen, Wei; Tang, Xue-Mei; Sun, Ji; Liu, Jian-Ren

2017-06-01

The association between intracranial internal carotid artery (IICA) calcification and lacunes, white matter hyperintensity (WMH), and cerebral microbleeds (CMBs) has been well researched. However, enlarged cerebral perivascular space (PVS) has not yet been reported to correlate with intracranial internal carotid artery calcification. Therefore, the primary aim of this study was to investigate the relationship between IICA calcification and enlarged PVS. A total of 189 patients with ischemic stroke in the middle cerebral artery territory who presented within 7 days of ictus from 2012 to 2015 were enrolled respectively. All patients were required to have undergone head computed tomography, magnetic resonance imaging, susceptibility-weighted magnetic resonance imaging, magnetic resonance angiography, or computed tomography angiography. Clinical characteristics were recorded. IICA calcification and enlarged PVS were semi-quantitatively evaluated, and the presence of lacunes, WMH, and CMBs was recorded. Of the 189 patients, 63.5% were male. Mean age of the patients was 68.6 ± 12.2 years. There were 104 patients with IICA calcification. Age, diabetes mellitus, lacunes, and white matter hyperintensity were significantly associated with IICA calcification (P < 0.05). Multivariate logistic regression analysis showed that age, diabetes mellitus, and lacunes were independent predictors of IICA calcification (P < 0.05). A lower risk of IICA calcification was found in patients with a higher enlarged PVS score (P = 0.004). Higher enlarged PVS scores were associated with a lesser degree of IICA calcification. There appears to be a relationship between reduced risk of IICA calcification and enlarged PVS.

Clinical interrogation and application of super-selective intracranial artery infusion chemotherapy for lung cancer patients with brain metastases.

PubMed

Rong, J; Chunhua, M; Yuan, L; Ning, M; Jinduo, L; Bin, W; Liwei, S

2015-11-01

The purpose of this study was to evaluate the clinical efficacy of super-selective intracranial artery infusion chemotherapy and to determine correlated prognostic parameters for advanced lung cancer patients with brain metastases. Fifty-four lung cancer patients with brain metastasis who had no previous treatment were enrolled for the study. These patients received super-selective intracranial artery infusion chemotherapy, as well as arterial infusion chemotherapy for primary and metastatic lesions. The procedure was performed once every 4 weeks. Patients were monitored to evaluate short-term clinical outcomes 4 weeks after the first 2 treatments, and follow-up visits performed every 4 weeks after the first 4 treatments until the appearance of disease progression or intolerable toxicity. All 54 cases were treated at least 4 times. The overall response rate was 55.56% (30/54), and the disease control rate was 85.19% (46/54). The median overall survival was 7 months, with a 95% confidence interval (CI) of 5.87-8.13 months, and the median progression-free survival was 4 months, with a 95% CI of 3.20-4.80 months. The 6-month survival rate and 1-year survival rate were 81.48% (44/54) and 18.52% (10/54), respectively. Super-selective intracranial artery infusion chemotherapy provides a clinically efficacious avenue of treatment for lung cancer patients with brain metastases. Pathological classification, Karnofsky performance status, and extracranial metastases may serve as reliable prognostic parameters in determining the clinical outcomes for lung cancer patients with brain metastases.

Affected twins in the familial intracranial aneurysm study.

PubMed

Mackey, Jason; Brown, Robert D; Sauerbeck, Laura; Hornung, Richard; Moomaw, Charles J; Koller, Daniel L; Foroud, Tatiana; Deka, Ranjan; Woo, Daniel; Kleindorfer, Dawn; Flaherty, Matthew L; Meissner, Irene; Anderson, Craig; Rouleau, Guy; Connolly, E Sander; Huston, John; Broderick, Joseph P

2015-01-01

Very few cases of intracranial aneurysms (IAs) in twins have been reported. Previous work has suggested that vulnerability to IA formation is heritable. Twin studies provide an opportunity to evaluate the impact of genetics on IA characteristics, including IA location. We therefore sought to examine IA location concordance, multiplicity, and rupture status within affected twin-pairs. The Familial Intracranial Aneurysm study was a multicenter study whose goal was to identify genetic and other risk factors for formation and rupture of IAs. The study required at least three affected family members or an affected sibling pair for inclusion. Subjects with fusiform aneurysms, an IA associated with an AVM, or a family history of conditions known to predispose to IA formation, such as polycystic kidney disease, Ehlers-Danlos syndrome, Marfan syndrome, fibromuscular dysplasia, or moyamoya syndrome were excluded. Twin-pairs were identified by birth date and were classified as monozygotic (MZ) or dizygotic (DZ) through DNA marker genotypes. In addition to zygosity, we evaluated twin-pairs by smoking status, major arterial territory of IAs, and rupture status. Location concordance was defined as the presence of an IA in the same arterial distribution (ICA, MCA, ACA, and vertebrobasilar), irrespective of laterality, in both members of a twin-pair. The Fisher exact test was used for comparisons between MZ and DZ twin-pairs. A total of 16 affected twin-pairs were identified. Location concordance was observed in 8 of 11 MZ twin-pairs but in only 1 of 5 DZ twin-pairs (p = 0.08). Three MZ subjects had unknown IA locations and comprised the three instances of MZ discordance. Six of the 11 MZ twin-pairs and none of the 5 DZ twin-pairs had IAs in the ICA distribution (p = 0.03). Multiple IAs were observed in 11 of 22 MZ and 5 of 10 DZ twin-pairs. Thirteen (13) of the 32 subjects had an IA rupture, including 10 of 22 MZ twins. We found that arterial location concordance was greater in

Risks of presurgical embolization of feeding arteries in 137 intracranial meningeal tumors.

PubMed

Law-ye, Bruno; Clarençon, Frédéric; Sourour, Nader-Antoine; Di Maria, Federico; Jean, Betty; Bonneville, Fabrice; Biondi, Alessandra; Iosif, Christina; Navarro, Soledad; Cornu, Philippe; Chiras, Jacques

2013-04-01

Embolization of extra-axial tumors has shown its effectiveness in reducing perisurgical blood loss. However, the complication rate of this procedure is poorly reported. We aimed to evaluate the rate of procedure-related complications and their risk factors. From 1998 to 2011, 193 consecutive patients (141 females, 52 males; mean age = 52.9 years) were referred to our institution for presurgical embolization of an extra-axial tumor (meningiomas: n = 178; solitary fibrous tumors: n = 3; other: n = 12). Of 193 patients, 137 (71 %) underwent 141 embolizations (by microparticles: n = 133; by glue: n = 8). The remaining 56 patients (29 %) were not embolized due to unstable catheterization or dangerous anastomosis. Occurrence of neurological deficit was systematically assessed during and after embolization. The risk factors of procedure-related neurological complications were evaluated. Neither intratumoral hemorrhage nor procedure-related death was reported. Two of the 137 patients (1.5 %) had ischemic events with permanent neurological deficit after microparticles embolization. One patient had cortical blindness and one had hemiparesis. Both complications involved the vertebrobasilar system. The first patient had direct intratumoral anastomosis between the middle and the posterior meningeal arteries (PMA); the second one had reflux in the vertebral artery during particles injection in the PMA. Occurrence of ischemic complication was not related to the size of the microparticles. Though embolization of meningeal tumors is considered as a safe technique, serious neurological complications may occur. Opening of dangerous anastomosis or uncontrolled reflux caused two neurological complications (1.5 %). The size of the microparticles was not associated with the occurrence of neurological event.

Time management in acute vertebrobasilar occlusion.

PubMed

Kamper, Lars; Rybacki, Konrad; Mansour, Michael; Winkler, Sven B; Kempkes, Udo; Haage, Patrick

2009-03-01

Acute vertebrobasilar occlusion (VBO) is associated with a high risk of stroke and death. Although local thrombolysis may achieve recanalization and improve outcome, mortality is still between 35% and 75%. However, without recanalization the chance of a good outcome is extremely poor, with mortality rates of 80-90%. Early treatment is a fundamental factor, but detailed studies of the exact time management of the diagnostic and interventional workflow are still lacking. Data on 18 patients were retrospectively evaluated. Time periods between symptom onset, admission to hospital, time of diagnosis, and beginning of intervention were correlated with postinterventional neurological status. The Glasgow Coma Scale and National Institute of Health Stroke Scale (NIHSS) were used to examine patients before and after local thrombolysis. Additionally, multivariate statistics were applied to reveal similarities between patients with neurological improvement. Primary recanalization was achieved in 77% of patients. The overall mortality was 55%. Major complications were intracranial hemorrhage and peripheral embolism. The time period from symptom onset to intervention showed a strong correlation with the postinterventional NIHSS as well as the patient's age, with the best results in a 4-h interval. Multivariate statistics revealed similarities among the patients. Evaluation of time management in acute VBO by multivariate statistics is a helpful tool for definition of similarities in this patient group. Similarly to the door-to-balloon time for acute coronary interventions, the chances for a good outcome depend on a short time interval between symptom onset and intervention. While the only manipulable time period starts with hospital admission, our results emphasize the necessity of efficient intrahospital workflow.

Lesion location, stability, and pretreatment management: factors affecting outcomes of endovascular treatment for vertebrobasilar atherosclerosis.

PubMed

Alexander, Matthew D; Rebhun, Jeffrey M; Hetts, Steven W; Kim, Anthony S; Nelson, Jeffrey; Kim, Helen; Amans, Matthew R; Settecase, Fabio; Dowd, Christopher F; Halbach, Van V; Higashida, Randall T; Cooke, Daniel L

2016-05-01

The proper role of endovascular treatment of cervicocerebral atherosclerosis is unclear. Posterior circulation disease has not been investigated as extensively as disease in the anterior circulation. In this study, we characterized the rates of technical success, transient ischemic attack, stroke, and death or disability, for both acute and elective endovascular treatment of atherosclerosis in the vertebrobasilar system. We identified patients with atherosclerosis of the vertebrobasilar circulation who underwent endovascular intervention at our hospital through retrospective medical record review, and evaluated the association between lesion and treatment features and subsequent stroke, death, or disability at 30 days and 1 year. We identified 136 lesions in 122 patients, including 13 interventions for acute strokes. Technical success was achieved in 123 of 136 cases (90.4%). Elective procedures had higher rates of technical success (6.5% vs 15.4%, p=0.21) and better clinical outcomes. In multivariate analysis, intracranial lesions were associated with more disability (modified Rankin Scale score >2) at 30 days (OR 7.1, p=0.01) and 1 year (OR 10, p=0.03). Patients with non-hypoperfusion related symptoms had fewer strokes at follow-up at 1 year when treated after an asymptomatic interval of >10 days compared with those treated within 10 days of the presenting symptoms (OR 0.2, p=0.03). Statin treatment prior to intervention was associated with favorable outcomes across several examined endpoints. Preoperative antiplatelet treatment was associated with lower rates of disability at 30 days and 1 year (OR 0.1, p<0.01 and OR 0.07, p=0.01, respectively), and preoperative anticoagulation treatment was associated with higher rates of death at 30 days, particularly when prescribed for reasons other than atrial fibrillation (OR 6.4, p=0.01). Endovascular treatment of symptomatic vertebrobasilar atherosclerosis can be performed safely and with good

Temporary subclavian steal to reduce intraprocedural embolic risk during detachable balloon occlusion of vertebrobasilar aneurysms: technical note with two case reports.

PubMed

Eckard, D A; O'Boynick, P L; Han, P P

1996-11-01

Unintentional intracerebral embolization is a serious, ever present threat during neurointerventional procedures. We have devised a method to reduce this intraprocedural risk in vertebral artery interventions by creating a temporary subclavian steal. For this technique, a temporary balloon occlusion catheter is advanced into the proximal subclavian artery via a femoral artery approach, while a second introducer catheter is passed into the target vertebral artery via an axillary artery access. The temporary occluding balloon is then inflated within the proximal subclavian artery, establishing a subclavian steal that diverts blood flow into the arm. Permanent balloon occlusion of the vertebral artery can then be accomplished without fear of intracerebral embolization. Two patients with vertebrobasilar junction aneurysms were successfully treated with detachable balloon embolization using this cerebral protection technique. The permanent occlusion balloons were easily passed through the introducer catheter without difficulty despite reversed vertebral artery flow. No complications were encountered, and the aneurysms were successfully occluded in both patients. Temporary subclavian steal can be easily created to reduce the risk of cerebral embolic complications when performing interventional neuroradiological procedures in the vertebral artery.

Autologous Fat Used for Facial Filling Can Lead to Massive Cerebral Infarction Through Middle Cerebral Artery or Facial Intracranial Branches.

PubMed

Wang, Xian; Wu, Min; Zhou, Xing; Liu, Hengdeng; Zhang, Yongchao; Wang, Haiping

2018-05-31

Autologous fat injection is a procedure aimed at eliminating grave defects in the skin surface by subcutaneous injection of the patient's fatty tissue. Fat embolism is a rare but severe complication of this procedure, especially cerebral infarction. It is first reported by Thaunat in 2004. were presented to the hospital with sudden unconsciousness and left limb weakness in 24 hours after facial fat injection. Brain computed tomography and magnetic resonance imaging were performed immediately after admission. Frontal temporoparietal decompressive craniectomy plus multiple treatments scheduled for patients. Pictures and videos were taken during follow-up. Figures are edited with Adobe Photograph CS6. Patients were diagnosed with extensive cerebral infarction of the right hemisphere through the middle cerebral artery or facial-intracranial branches. Routine cosmetic procedures of facial fat injections could cause devastating and even fatal complications to patients. The small volume of fat grafts can be inserted through the internal carotid artery or go through the communicating branches between the facial artery and the intracranial artery into the brain.

3D printing of intracranial artery stenosis based on the source images of magnetic resonance angiograph.

PubMed

Xu, Wei-Hai; Liu, Jia; Li, Ming-Li; Sun, Zhao-Yong; Chen, Jie; Wu, Jian-Huang

2014-08-01

Three dimensional (3D) printing techniques for brain diseases have not been widely studied. We attempted to 'print' the segments of intracranial arteries based on magnetic resonance imaging. Three dimensional magnetic resonance angiography (MRA) was performed on two patients with middle cerebral artery (MCA) stenosis. Using scale-adaptive vascular modeling, 3D vascular models were constructed from the MRA source images. The magnified (ten times) regions of interest (ROI) of the stenotic segments were selected and fabricated by a 3D printer with a resolution of 30 µm. A survey to 8 clinicians was performed to evaluate the accuracy of 3D printing results as compared with MRA findings (4 grades, grade 1: consistent with MRA and provide additional visual information; grade 2: consistent with MRA; grade 3: not consistent with MRA; grade 4: not consistent with MRA and provide probable misleading information). If a 3D printing vessel segment was ideally matched to the MRA findings (grade 2 or 1), a successful 3D printing was defined. Seven responders marked "grade 1" to 3D printing results, while one marked "grade 4". Therefore, 87.5% of the clinicians considered the 3D printing were successful. Our pilot study confirms the feasibility of using 3D printing technique in the research field of intracranial artery diseases. Further investigations are warranted to optimize this technique and translate it into clinical practice.

Angiographic Structural Differentiation between Native Arteriogenesis and Therapeutic Synangiosis in Intracranial Arterial Steno-Occlusive Disease.

PubMed

Ooi, Y C; Laiwalla, A N; Liou, R; Gonzalez, N R

2016-06-01

Encephaloduroarteriosynangiosis has been shown to generate collateral vessels from the extracranial-to-intracranial circulation in patients with Moyamoya disease and intracranial arterial steno-occlusive disease. The mechanisms involved are not well-understood. We hypothesized that angiogenesis is the leading mechanism forming collaterals after encephaloduroarteriosynangiosis because there are no pre-existing connections. Angiogenesis-generated collaterals should exhibit higher architectural complexity compared with innate collaterals. Pre- and postoperative digital subtraction angiograms were analyzed in patients enrolled in a prospective trial of encephaloduroarteriosynangiosis surgery. Branching angioscore, tortuosity index, and local connected fractal dimension were compared between innate and postoperative collaterals. One hundred one angiograms (50 preoperative, 51 postoperative) were analyzed from 44 patients (22 with intracranial atherosclerosis and 22 with Moyamoya disease). There was a significantly higher median branching angioscore (13 versus 4, P < .001) and a lower median tortuosity index (1.08 versus 1.76, P < .001) in the encephaloduroarteriosynangiosis collaterals compared with innate collaterals. Higher mean local fractal dimension peaks (1.28 ± 0.1 versus 1.16 ± 0.11, P < .001) were observed in the encephaloduroarteriosynangiosis collaterals compared with innate collaterals for both intracranial atherosclerosis (P < .001) and Moyamoya disease (P < .001) groups. The observed increase in high connectivity was greater in the intracranial atherosclerosis group compared with patients with Moyamoya disease (P = .01). The higher median branching angioscore and local connected fractal dimension, along with the lower median tortuosity index of encephaloduroarteriosynangiosis collaterals, are consistent with the greater complexity observed in the process of sprouting and splitting associated with angiogenesis. © 2016 by American Journal of

Intracranial and visceral arterial embolization of a cardiac myxoma that was treated with endovascular stent-retriever therapy

PubMed Central

Thibodeau, Cheryl; McGowan, Amelia

2016-01-01

We report a case of a ruptured left atrial myxoma with multiple synchronous sites of embolization, including the intracranial cerebral (left middle cerebral artery (MCA) and basilar), visceral (renal, superior mesenteric artery (SMA)) and peripheral circulatory beds (aorta and lower extremities). This synchronous embolization resulted in a catastrophic neurologic and systemic event. An intracranial stent retriever was used to restore cerebral circulation in the symptomatic left MCA distribution, which resulted in resolution of the acute neurologic deficits. Endovascular and open surgical interventions were later performed to address the residual cardiac mass and other embolic sites. The patient survived the event with the loss of her right leg below the knee and a transient dialysis requirement. The purpose of this case report is to document the successful utilization of a stent-retriever device in removing an embolized myxoma from the cerebral circulation, to review the unique pathology of this source of embolic stroke and to reiterate the importance of considering embolic and non-thrombotic etiologies of acute ischemic stroke, especially in atypical patient populations and patient presentations. PMID:27306523

Thirty-Day Outcome of a Multicenter Registry Study of Stenting for Symptomatic Intracranial Artery Stenosis in China.

PubMed

Miao, Zhongrong; Zhang, Yong; Shuai, Jie; Jiang, Changchun; Zhu, Qiyi; Chen, Kangning; Liu, Li; Li, Baomin; Shi, Xiangqun; Gao, Lianbo; Liu, Yajie; Wang, Feng; Li, Yongli; Liu, Tieyan; Zheng, Hongbo; Wang, Yilong; Wang, Yongjun

2015-10-01

Although recent trials have suggested that stenting is worse than medical therapy for patients with severe symptomatic intracranial atherosclerotic stenosis, it is not clear whether this conclusion applies to a subset of patients with hypoperfusion symptoms. To justify for a new trial in China, we performed a multicenter prospective registry study to evaluate the safety and efficacy of endovascular stenting within 30 days for patients with severe symptomatic intracranial atherosclerotic stenosis. Patients with symptomatic intracranial atherosclerotic stenosis caused by 70% to 99% stenosis combined with poor collaterals were enrolled. The patients were treated either with balloon-mounted stent or with balloon predilation plus self-expanding stent as determined by the operators following a guideline. The primary outcome within 30 days is stroke, transient ischemic attack, and death after stenting. The secondary outcome is successful revascularization. The baseline characteristics and outcomes of the 2 treatment groups were compared. From September 2013 to January 2015, among 354 consecutive patients, 300 patients (aged 58.3±9.78 years) were recruited, including 159 patients treated with balloon-mounted stent and 141 patients with balloon plus self-expanding stent. The 30-day rate of stroke, transient ischemic attack, and death was 4.3%. Successful revascularization was 97.3%. Patients treated with balloon-mounted stent were older, less likely to have middle cerebral artery lesions, more likely to have vertebral artery lesions, more likely to have Mori A lesions, less likely to have Mori C lesions, and likely to have lower degree of residual stenosis than patients treated with balloon plus self-expanding stent. The short-term safety and efficacy of endovascular stenting for patients with severe symptomatic intracranial atherosclerotic stenosis in China is acceptable. Balloon-mounted stent may have lower degree of residual stenosis than self-expanding stent. URL: http

Application of Micromirror in Microsurgical Clipping to the Intracranial Aneurysms.

PubMed

Zhao, Chao; Ma, Zhiguo; Zhang, Yuhai; Mou, Shanling; Yang, Yunxue; Yang, Yonglin; Sun, Guoqing; Yao, Weicheng

2018-05-01

The aim of the study was to explore the values and disadvantages of micromirror in the intracranial aneurysm clipping surgery. Micromirror was used to assist microsurgical clipping to 36 intracranial aneurysms in 31 patients, of which 3 were carotid-ophthalmic artery aneurysms, 3 were anterior choroidal artery aneurysms, 11 were posterior communicating artery aneurysms, 7 were middle cerebral artery aneurysms, 10 were anterior communicating artery or anterior cerebral artery aneurysms, and the rest were a posterior cerebral artery aneurysm and a posterior inferior cerebellar artery aneurysm. The micromirror was used before and after clipping to observe the anatomic features of necks hidden behind and medial to aneurysms, to visualize surrounding neurovascular structures, and to verify the optimal clipping position. Intraoperative indocyanine green fluorescein angiography, postoperative computerized tomography angiography, and digital subtraction angiography confirmed the success of sufficient clipping. Intraoperative indocyanine green angiography, postoperative computerized tomography angiography , or digital subtraction angiography were performed and showed no case of wrong or insufficient clipping of aneurysm. Micromirror-assisted microsurgical clipping to the intracranial aneurysm is safe, sufficient, convenient, and practical.

Hypertrophic remodeling and increased arterial stiffness in patients with intracranial aneurysms.

PubMed

Maltete, David; Bellien, Jeremy; Cabrejo, Lucie; Iacob, Michele; Proust, François; Mihout, Bruno; Thuillez, Christian; Guegan-Massardier, Evelyne; Joannides, Robinson

2010-08-01

Because an underlying arteriopathy might contribute to the development of intracranial aneurysms (IAs), we assessed the elastic properties of proximal conduit arteries in patients with IA. In 27 patients with previous ruptured IA and 27 control subjects matched for age, gender and BMI, we determined arterial pressure, internal diameter, intima-media thickness (IMT), circumferential wall stress (CWS) and elastic modulus (wall stiffness) in common carotid arteries using applanation tonometry and echotracking. Moreover, carotid augmentation index (AIx, arterial wave reflections) and carotid-to-femoral pulse wave velocity (PWV, aortic stiffness) were assessed. Compared with controls, patients with IA exhibited higher brachial and carotid systolic and diastolic blood pressures, with similar brachial but higher carotid artery pulse pressure (35 + or - 6mm Hg vs. 41 + or - 8mm Hg, P=0.014). Moreover, patients have higher PWV (7.8 + or - 1.2ms(-1) vs. 8.3 + or - 1.1ms(-1), P=0.048) and AIx (15.8 + or - 10.8% vs. 21.1 + or - 8.5%, P<0.001) which contributes to increase carotid blood pressures. Furthermore, carotid IMT was higher in patients (546 + or - 64 microm vs. 642 + or - 70 microm, P<0.001) without difference in diameter suggesting an adaptive hypertrophy. However, patients display a lower CWS (61.6 + or - 9.2 kPa vs. 56.9 + or - 10.3 kPa, P=0.007) and no correlation between IMT and pulse pressure (r=0.152, P=NS) in contrast to controls (r=0.539, P<0.001) showing the contribution of a pressure-independent process. Finally, despite this lesser CWS, elastic modulus was increased in patients (310 + or - 105 kPa vs. 383 + or - 174 kPa, P=0.026). This study demonstrates that patients with IA display a particular carotid artery phenotype with an exaggerated hypertrophic remodeling and altered elastic properties. Thus, a systemic arteriopathy might contribute, together with the arterial wall fatiguing effect of the increased pulsatile stress, to the pathogenesis of IA

Arterial supply of the lower cranial nerves: a comprehensive review.

PubMed

Hendrix, Philipp; Griessenauer, Christoph J; Foreman, Paul; Loukas, Marios; Fisher, Winfield S; Rizk, Elias; Shoja, Mohammadali M; Tubbs, R Shane

2014-01-01

The lower cranial nerves receive their arterial supply from an intricate network of tributaries derived from the external carotid, internal carotid, and vertebrobasilar territories. A contemporary, comprehensive literature review of the vascular supply of the lower cranial nerves was performed. The vascular supply to the trigeminal, facial, vestibulocochlear, glossopharyngeal, vagus, spinal accessory, and hypoglossal nerves are illustrated with a special emphasis on clinical issues. Frequently the external carotid, internal carotid, and vertebrobasilar territories all contribute to the vascular supply of an individual cranial nerve along its course. Understanding of the vasculature of the lower cranial nerves is of great relevance for skull base surgery. Copyright © 2013 Wiley Periodicals, Inc.

High Blood Pressure Increases the Risk of Poor Outcome at Discharge and 12-month Follow-up in Patients with Symptomatic Intracranial Large Artery Stenosis and Occlusions: Subgroup analysis of the CICAS Study.

PubMed

Yu, Dan-Dan; Pu, Yue-Hua; Pan, Yue-Song; Zou, Xin-Ying; Soo, Yannie; Leung, Thomas; Liu, Li-Ping; Wang, David Z; Wong, Ka-Sing; Wang, Yi-Long; Wang, Yong-Jun

2015-06-01

The purpose of this study was to discuss the relationship between blood pressure and prognosis of patients with symptomatic intracranial arterial stenosis. Data on 2426 patients with symptomatic intracranial large artery stenosis and occlusion who participated in the Chinese Intracranial Atherosclerosis (CICAS) study were analyzed. According to the JNC 7 criteria, blood pressure of all patients was classified into one of the four subgroups: normal, prehypertension, hypertension stage I, and hypertension stage II. Poor outcomes were defined as death and functional dependency (mRS 3-5) at discharge or at 1 year. For patients with intracranial stenosis of 70% to 99%, the rate of poor outcome at discharge was 19.3%, 23.5%, 26.8%, and 39.8% (P = 0.001) for each blood pressure subgroup. For patients with intracranial large artery occlusion, the rates were 17.6%, 22.1%, 29.5%, and 49.8%, respectively (P < 0.0001). The rate of poor outcome at 12-month follow-up was 12.6%, 15.3%, 28.5%, and 27.9% (P = 0.0038) in patients with stenosis of 70% to 99% for each blood pressure subgroup and 11.6%, 21.5%, 23.9%, 35.1% (P < 0.0001) in patients with occlusion. For patients with severe intracranial arterial stenosis or occlusion, higher hypertension stages are associated with an increased risk of poor outcome at discharge and 12-month follow-up. © 2015 The Authors. CNS Neuroscience & Therapeutics Published by John Wiley & Sons Ltd.

Treatment Challenges of a Primary Vertebral Artery Aneurysm Causing Recurrent Ischemic Strokes.

PubMed

Strambo, Davide; Peruzzotti-Jametti, Luca; Semerano, Aurora; Fanelli, Giovanna; Simionato, Franco; Chiesa, Roberto; Rinaldi, Enrico; Martinelli, Vittorio; Comi, Giancarlo; Bacigaluppi, Marco; Sessa, Maria

2017-01-01

Background . Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; surgical and endovascular therapy options are debated and long-term complication may occur. Case Report . A 53-year-old man affected by neurofibromatosis type 1 (NF1) came to our attention for recurrent vertebrobasilar embolic strokes, caused by a primary giant, partially thrombosed, fusiform aneurysm of the left extracranial vertebral artery. The aneurysm was treated by endovascular approach through deposition of Guglielmi Detachable Coils in the proximal segment of the left vertebral artery. Six years later the patient presented stroke recurrence. Cerebral angiography and Color Doppler Ultrasound well characterized the unique hemodynamic condition developed over the years responsible for the new embolic event: the aneurysm had been revascularized from its distal portion by reverse blood flow coming from the patent vertebrobasilar axis. A biphasic Doppler signal in the left vertebral artery revealed a peculiar behavior of the blood flow, alternately directed to the aneurysm and backwards to the basilar artery. Surgical ligation of the distal left vertebral artery and excision of the aneurysm were thus performed. Conclusion . This is the first described case of NF1-associated extracranial vertebral artery aneurysm presenting with recurrent embolic stroke. Complete exclusion of the aneurysm from the blood circulation is advisable to achieve full resolution of the embolic source.

Intravascular ultrasound for intracranial angioplasty and stent placement: technical case report.

PubMed

Wehman, J Christopher; Holmes, David R; Hanel, Ricardo A; Levy, Elad I; Hopkins, L Nelson

2006-10-01

Intravascular ultrasound (IVUS) imaging has been used extensively in coronary artery interventions and has provided invaluable information for the understanding and treatment of coronary arterial disease. We present here the first description, to our knowledge, of IVUS-guided intracranial arterial interventions in the clinical setting. Two patients underwent intracranial angioplasty and stent placement with the assistance of IVUS for the evaluation of their lesions. One patient underwent stenting to treat an occlusive dissection of the left internal carotid artery that occurred during arteriovenous malformation embolization. Another patient underwent angioplasty and stenting for high-grade restenosis of a basilar artery atherosclerotic lesion. Both patients underwent successful revascularization procedures. The patient with the dissection had a small intraventricular and parenchymal hemorrhage documented by computed tomography 4 hours after treatment, but did not develop hydrocephalus or further hemorrhage. Both patients did well clinically and had no permanent neurological deficits. IVUS provided important information in terms of lesion evaluation, stent selection, and stent placement in each case. IVUS of the intracranial circulation may assist the performance of intracranial angioplasty and stenting. It provides useful information that can affect clinical decisions. It may prove to be a valuable tool in clinical use and enhance our understanding of vascular disease of the intracranial circulation, as it has in the coronary circulation.

Giant intracranial aneurysm embolization with a yield stress fluid material: insights from CFD analysis.

PubMed

Wang, Weixiong; Graziano, Francesca; Russo, Vittorio; Ulm, Arthur J; De Kee, Daniel; Khismatullin, Damir B

2013-01-01

The endovascular treatment of intracranial aneurysms remains a challenge, especially when the aneurysm is large in size and has irregular, non-spherical geometry. In this paper, we use computational fluid dynamics to simulate blood flow in a vertebro-basilar junction giant aneurysm for the following three cases: (1) an empty aneurysm, (2) an aneurysm filled with platinum coils, and (3) an aneurysm filled with a yield stress fluid material. In the computational model, blood and the coil-filled region are treated as a non-Newtonian fluid and an isotropic porous medium, respectively. The results show that yield stress fluids can be used for aneurysm embolization provided the yield stress value is 20 Pa or higher. Specifically, flow recirculation in the aneurysm and the size of the inflow jet impingement zone on the aneurysm wall are substantially reduced by yield stress fluid treatment. Overall, this study opens up the possibility of using yield stress fluids for effective embolization of large-volume intracranial aneurysms.

Whole-body mathematical model for simulating intracranial pressure dynamics

NASA Technical Reports Server (NTRS)

Lakin, William D. (Inventor); Penar, Paul L. (Inventor); Stevens, Scott A. (Inventor); Tranmer, Bruce I. (Inventor)

2007-01-01

A whole-body mathematical model (10) for simulating intracranial pressure dynamics. In one embodiment, model (10) includes 17 interacting compartments, of which nine lie entirely outside of intracranial vault (14). Compartments (F) and (T) are defined to distinguish ventricular from extraventricular CSF. The vasculature of the intracranial system within cranial vault (14) is also subdivided into five compartments (A, C, P, V, and S, respectively) representing the intracranial arteries, capillaries, choroid plexus, veins, and venous sinus. The body's extracranial systemic vasculature is divided into six compartments (I, J, O, Z, D, and X, respectively) representing the arteries, capillaries, and veins of the central body and the lower body. Compartments (G) and (B) include tissue and the associated interstitial fluid in the intracranial and lower regions. Compartment (Y) is a composite involving the tissues, organs, and pulmonary circulation of the central body and compartment (M) represents the external environment.

Comparison of 3D TOF-MRA and 3D CE-MRA at 3T for imaging of intracranial aneurysms.

PubMed

Cirillo, Mario; Scomazzoni, Francesco; Cirillo, Luigi; Cadioli, Marcello; Simionato, Franco; Iadanza, Antonella; Kirchin, Miles; Righi, Claudio; Anzalone, Nicoletta

2013-12-01

To compare 3T elliptical-centric CE MRA with 3T TOF MRA for the detection and characterization of unruptured intracranial aneurysms (UIAs), by using digital subtracted angiography (DSA) as reference. Twenty-nine patients (12 male, 17 female; mean age: 62 years) with 41 aneurysms (34 saccular, 7 fusiform; mean diameter: 8.85 mm [range 2.0-26.4mm]) were evaluated with MRA at 3T each underwent 3D TOF-MRA examination without contrast and then a 3D contrast-enhanced (CE-MRA) examination with 0.1mmol/kg bodyweight gadobenate dimeglumine and k-space elliptic mapping (Contrast ENhanced Timing Robust Angiography [CENTRA]). Both TOF and CE-MRA images were used to evaluate morphologic features that impact the risk of rupture and the selection of a treatment. Almost half (20/41) of UIAs were located in the internal carotid artery, 7 in the anterior communicating artery, 9 in the middle cerebral artery and 4 in the vertebro-basilar arterial system. All patients also underwent DSA before or after the MR examination. The CE-MRA results were in all cases consistent with the DSA dataset. No differences were noted between 3D TOF-MRA and CE-MRA concerning the detection and location of the 41 aneurysms or visualization of the parental artery. Differences were apparent concerning the visualization of morphologic features, especially for large aneurysms (>13 mm). An irregular sac shape was demonstrated for 21 aneurysms on CE-MRA but only 13/21 aneurysms on 3D TOF-MRA. Likewise, CE-MRA permitted visualization of an aneurismal neck and calculation of the sac/neck ratio for all 34 aneurysms with a neck demonstrated at DSA. Conversely, a neck was visible for only 24/34 aneurysms at 3D TOF-MRA. 3D CE-MRA detected 15 aneurysms with branches originating from the sac and/or neck, whereas branches were recognized in only 12/15 aneurysms at 3D TOF-MRA. For evaluation of intracranial aneurysms at 3T, 3D CE-MRA is superior to 3D TOF-MRA for assessment of sac shape, detection of aneurysmal neck, and

Acute Hearing Loss Caused by Decreasing Anterior Inferior Cerebellar Arterial Perfusion in a Patient with Vertebral Artery Stenosis.

PubMed

Fukuda, Rintaro; Miyamoto, Nobukazu; Hayashida, Arisa; Ueno, Yuji; Yamashiro, Kazuo; Tanaka, Ryota; Hattori, Nobutaka

2017-06-01

We report a case of bilateral hearing loss caused by decreased vascular flow in the anterior inferior cerebellar artery (AICA) territory. A 74-year-old man who experienced right hearing loss 5 months ago presented with bilateral deafness and right cerebellar ataxia; however, no ischemic lesion was detected in the bilateral AICA area. After stroke treatment, hearing loss was improved. One month later, we obtained blood flow improvement in the left AICA territory on single-photon-emission computed tomography and vertebral artery stenosis on magnetic resonance angiography. Therefore, clinicians should recognize that bilateral hearing loss may be related to stroke in the vertebrobasilar artery area. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

[Application of Silicone Rubber Stents in Intracranial Arterial Microanastomosis for Vessels with Intimal Dissection:A Technical Note].

PubMed

Funatsu, Takayuki; Kawashima, Akitsugu; Mochizuki, Yuichi; Kikuta, Yoshichika; Imanaka, Kousuke; Okada, Yoshikazu

2015-10-01

Intracranial arterial microanastomosis remains an important neurosurgical technique. Intimal dissection of donor or recipient arteries can cause bypass failure. We used a silicone rubber stent while performing arterial microanastomoses, and achieved an excellent postoperative patency rate. In this study, we evaluated the efficacy of the stent in cases of extensive intimal dissection. In 5 cases involving extensive intimal dissection of vessels out of a total of 856 microanastomoses that were performed between November 2000 and August 2014, we placed a silicone rubber stent in the lumen of the recipient artery for donor to recipient suturing. Surgery was performed in 3 cases of cerebrovascular atherosclerotic disease and in 2 cases requiring cerebral revascularization for the treatment of aneurysm recurrence. In one of the 5 cases in which arterial microanastomosis was performed in the spasm period after subarachnoid hemorrhage, a patent anastomosis could not be confirmed. We observed the following advantages of silicone stent use: clear visualization of the orifice created in the vessel, avoidance of suturing or damaging the contralateral side vessel edges, and maintenance of the shape of the anastomosed vessel segment. These advantages made it easier to visualize the intima and to achieve fixation by using tacking sutures.

Effects of hyperbaric oxygen on intracranial pressure and cerebral blood flow in experimental cerebral oedema1

PubMed Central

Miller, J. D.; Ledingham, I. McA.; Jennett, W. B.

1970-01-01

Increased intracranial pressure was induced in anaesthetized dogs by application of liquid nitrogen to the dura mater. Intracranial pressure and cerebral blood flow were measured, together with arterial blood pressure and arterial and cerebral venous blood gases. Carbon dioxide was administered intermittently to test the responsiveness of the cerebral circulation, and hyperbaric oxygen was delivered at intervals in a walk-in hyperbaric chamber, pressurized to two atmospheres absolute. Hyperbaric oxygen caused a 30% reduction of intracranial pressure and a 19% reduction of cerebral blood flow in the absence of changes in arterial PCO2 or blood pressure, but only as long as administration of carbon dioxide caused an increase in both intracranial pressure and cerebral blood flow. When carbon dioxide failed to influence intracranial pressure or cerebral blood flow then hyperbaric oxygen had no effect. This unresponsive state was reached at high levels of intracranial pressure. Images PMID:5497875

Effect of lipid-lowering therapy on the progression of intracranial arterial stenosis.

PubMed

Tan, Teng-Yeow; Kuo, Yeh-Lin; Lin, Wei-Che; Chen, Ting-Yao

2009-02-01

Intracranial arterial stenosis (IAS) is a severe disease with a high recurrent stroke rate even under the best medical treatment. Statins have been demonstrated to prevent stroke and to slow or halt atherosclerosis progression. This study was performed to observe the effect of atorvastatin on the progression of IAS, explore the factors associated with atherosclerosis regression and the recurrent rate of stroke. A hospital-base observation study enrolled 40 stroke patients with middle cerebral artery (MCA) or/and basilar artery (BA) stenosis. All participants had hyperlipidemia and were given atorvastatin 40 mg per day for at least six months. IAS was assessed by magnetic resonance angiogram (MRA) at the time of enrollment and then at least six months later. The primary outcome was the progression of IAS. All patients were also given antiplatelet agents for stroke prevention. At the end of the study, 23 (58 %), 15 (38 %) and 2 (4 %) patients had regressed, stationary and progressed IAS, respectively. Females were likely to have regressed IAS. The recurrent stroke rate was 18 %. Among the 54 stenotic vessels, 29 (54 %) vessels were assessed as improvement in stenosis. Compared with other studies, more regressed, stationary IAS and less progressed IAS were found in our study. Female gender was likely to have regressed IAS after statin treatment. Further clinical outcome trials are required to assess the effects of such therapy on morbidity and mortality in this particular group of patients.

Vertebrobasilar ectasia in patients with lacunar stroke: the secondary prevention of small subcortical strokes trial.

PubMed

Nakajima, Makoto; Pearce, Lesly A; Ohara, Nobuyuki; Field, Thalia S; Bazan, Carlos; Anderson, David C; Hart, Robert G; Benavente, Oscar R

2015-05-01

The clinical implications of vertebrobasilar ectasia (VBE) in patients with cerebral small-artery disease are not well defined. We investigated whether VBE is associated with recurrent stroke, major hemorrhage, and death in a large cohort of patients with recent lacunar stroke. Maximum diameters of the vertebral and basilar arteries were measured by magnetic resonance angiography and computed tomographic angiography in 2621 participants in the Secondary Prevention of Small Subcortical Strokes trial. VBE was defined a priori as basilar artery greater than 4.5 mm and/or vertebral artery greater than 4.0 mm. Patient characteristics and risks of stroke recurrence and mortality during follow-up (median, 3.5 years) were compared between patients with and without VBE. VBE affecting 1 or more arteries was present in 200 (7.6%) patients. Patient features independently associated with VBE were increasing age, male sex, white race ethnicity, hypertension, and higher baseline diastolic blood pressure. Baseline systolic blood pressure was inversely associated with VBE. After adjustment for other risk factors, VBE was not predictive of recurrent stroke (hazard ratio [HR], 1.3; 95% confidence interval [CI], .85-1.9) or major hemorrhage (HR, 1.5; CI, .94-2.6), but was of death (HR, 1.7; CI, 1.1-2.7). In this large well-characterized cohort of patients with recent lacunar stroke, VBE was predictive of death but not of recurrent stroke or major hemorrhage. In these exploratory analyses, the frequency of VBE was directly related to diastolic blood pressure but inversely related to systolic blood pressure. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Fluid-attenuated inversion recovery vascular hyperintensities in predicting cerebral hyperperfusion after intracranial arterial stenting.

PubMed

Wan, Chih-Cheng; Chen, David Yen-Ting; Tseng, Ying-Chi; Yan, Feng-Xian; Lee, Kun-Yu; Chiang, Chen-Hua; Chen, Chi-Jen

2017-08-01

No reliable imaging sign predicting cerebral hyperperfusion after intracranial arterial stenting (IAS) had been described in the literature. This study evaluated the effect of fluid-attenuated inversion recovery vascular hyperintensities (FVHs), also called hyperintense vessel sign on T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) MR images, in predicting significant increase in cerebral blood flow (CBF) defined by arterial spin labeling (ASL) after IAS. We reviewed ASL CBF images and T2-FLAIR MR images before (D0), 1 day after (D1), and 3 days after (D3) IAS of 16 patients. T1-weighted MR images were used as cerebral maps for calculating CBF. The changes in CBF values after IAS were calculated in and compared among stenting and nonstenting vascular territories. An increase more than 50% of CBF was considered as hyperperfusion. The effect of FVHs in predicting hyperperfusion was calculated. The D1 CBF value was significantly higher than the D0 CBF value in stenting vascular, contralateral anterior cerebral artery, contralateral middle cerebral artery, and contralateral posterior cerebral artery (PCA) territories (all P < .05). The D1 and D3 CBF values were significantly higher than the D0 CBF value in overall vascular (P < .001), overall nonstenting vascular (P < .001), and ipsilateral PCA (P < .05) territories. The rate of more than 50% increases in CBF was significantly higher in patients who exhibited asymmetric FVHs than in those who did not exhibit these findings. FVHs could be a critical predictor of a significant increase in CBF after IAS.

21 CFR 882.5175 - Carotid artery clamp.

Code of Federal Regulations, 2014 CFR

2014-04-01

... carotid artery to treat intracranial aneurysms (balloonlike sacs formed on blood vessels) or other intracranial vascular malformations that are difficult to attach directly by reducing the blood pressure and... (the principal artery in the neck that supplies blood to the brain) and has a removable adjusting...

21 CFR 882.5175 - Carotid artery clamp.

Code of Federal Regulations, 2013 CFR

2013-04-01

... carotid artery to treat intracranial aneurysms (balloonlike sacs formed on blood vessels) or other intracranial vascular malformations that are difficult to attach directly by reducing the blood pressure and... (the principal artery in the neck that supplies blood to the brain) and has a removable adjusting...

21 CFR 882.5175 - Carotid artery clamp.

Code of Federal Regulations, 2010 CFR

2010-04-01

... carotid artery to treat intracranial aneurysms (balloonlike sacs formed on blood vessels) or other intracranial vascular malformations that are difficult to attach directly by reducing the blood pressure and... (the principal artery in the neck that supplies blood to the brain) and has a removable adjusting...

21 CFR 882.5175 - Carotid artery clamp.

Code of Federal Regulations, 2012 CFR

2012-04-01

... carotid artery to treat intracranial aneurysms (balloonlike sacs formed on blood vessels) or other intracranial vascular malformations that are difficult to attach directly by reducing the blood pressure and... (the principal artery in the neck that supplies blood to the brain) and has a removable adjusting...

21 CFR 882.5175 - Carotid artery clamp.

Code of Federal Regulations, 2011 CFR

2011-04-01

... carotid artery to treat intracranial aneurysms (balloonlike sacs formed on blood vessels) or other intracranial vascular malformations that are difficult to attach directly by reducing the blood pressure and... (the principal artery in the neck that supplies blood to the brain) and has a removable adjusting...

Epidemiology of Intracranial and Extracranial Large Artery Stenosis in a Population-Based Study of Stroke in the Middle East.

PubMed

Saber, Hamidreza; Amiri, Amin; Thrift, Amanda G; Stranges, Saverio; Bavarsad Shahripour, Reza; Farzadfard, Mohammad T; Mokhber, Naghmeh; Behrouz, Réza; Azarpazhooh, Mahmoud Reza

2017-01-01

Intracranial large-artery disease (LAD) is a predominant vascular lesion found in patients with stroke of Asian, African, and Hispanic origin, whereas extracranial LAD is more prevalent among Caucasians. These patterns are not well-established in the Middle East. We aimed to characterize the incidence, risk factors, and long-term outcome of LAD strokes in a Middle-Eastern population. The Mashhad Stroke Incidence Study is a community-based study that prospectively ascertained all cases of stroke among the 450,229 inhabitants of Mashhad, Iran between 2006 and 2007. Ischemic strokes were classified according to the TOAST criteria. Duplex-ultrasonography (98.6%), MR-angiography (8.3%), CT-angiography (11%), and digital-subtraction angiography (9.7%) were performed to identify involvements. Vessels were considered stenotic when the lumen was occluded by >50%. We identified 72 cases (15.99 per 100,000) of incident LAD strokes (mean age 67.6 ± 11.7). Overall, 77% had extracranial LAD (58% male, mean age 69.8 ± 10.3; 50 [89%] carotid vs. 6 [11%] vertebral artery), and the remaining 23% (56% male, mean age 60.2 ± 13.4; 69% anterior-circulation stenosis) had intracranial LAD strokes. We were unable to detect differences in case-fatality between extracranial (1-year: 28.6%; 5-year: 59.8%) and intracranial diseases (1-year: 18.8%; 5-year: 36.8%; log-rank; p = 0.1). Extracranial carotid stenosis represents the majority of LAD strokes in this population. Thus, public health strategies may best be developed in such a way that they are targeted toward the risk factors that contribute to extracranial stenosis. © 2017 S. Karger AG, Basel.

Delayed Visual Loss and Its Surgical Rescue Following Extracranial-Intracranial Arterial Bypass and Native Internal Carotid Artery Sacrifice.

PubMed

Li, Lai-Fung; Leung, Gilberto Ka-Kit; Lui, Wai-Man

2017-02-01

High-flow extracranial-intracranial (EC-IC) bypass followed by sacrifice of the native internal carotid artery (ICA) is a recognized treatment option for giant ICA aneurysm and skull base tumor involving the ICA. Distal clipping at the supraclinoid portion of the ICA is technically straightforward, but it can potentially compromise ophthalmic artery (OA) perfusion. Because of the extensive EC-IC anastomoses with the OA, visual symptoms are fortunately uncommon. We report a patient who developed complete blindness after distal trapping of the supraclinoid ICA; it was reversed after emergency clip removal. Our patient is a 47-year-old man with recurrent nasopharyngeal carcinoma in close proximity to the left petrosal ICA. The first stage of the procedure involved an EC-IC bypass using radial artery graft, followed by a second stage with combined craniofacial excision. Trapping of the native ICA was achieved using a permanent aneurysm clip placed at the supraclinoid ICA distal to the origin of the OA. He complained of a new onset of complete left eye visual loss approximately 6 hours after the distal aneurysm clip was applied. He was immediately sent to the operating theatre for the removal of the supraclinoid aneurysm clip. On the next day, his vision improved and left pupil became reactive again. OA flow following ICA trapping is complicated and precarious. Delayed onset of visual loss is possible. Prompt action by direct exploration and clip removal is needed and can be effective in reversing blindness. Copyright © 2016 Elsevier Inc. All rights reserved.

Low scores on the Benton Facial Recognition Test associated with vertebrobasilar insufficiency.

PubMed

Koçer, Abdulkadir; Koçer, Emel; Beşir, Halit; Dikici, Süber; Domaç, Füsun; Ercan, Nurten

2013-05-01

Decreased posterior cerebral circulation has been observed in patients with vertebrobasilar insufficiency (VBI). Reduced cerebral perfusion may have an impact on mental performance as measured by the Benton Facial Recognition Test (BFRT). We evaluated the usefulness of BFRT in identifying cognitive decline in patients with VBI by correlating test performance with total blood flow in the vertebrobasilar system and other variables such as educational level and gender. Thirty-three participants without dementia (mini-mental state examination; MMSE >27) and cranial magnetic resonance imaging abnormality, but with atherosclerotic risk factors were involved in the study. Nineteen subjects had a total vertebrobasilar flow volume less than 200 ml/min (Group I), and 14 subjects had a flow volume more than 200 ml/min (Group II). The groups were similar in regard to gender, age, and educational level. BFRT results were 19.53 ± 3.12 and 22.36 ± 2.73 for Groups I and II, respectively (p=0.01). The educational level was the main factor affecting the BFRT score in Group I (p=0.04). BFRT is clearly impaired in VBI as measured by Doppler ultrasound examination. We concluded that the test appears to adequately distinguish cognitive levels between VBI and other patients. Additionally, our results suggest that education is associated with BFRT results, and for normative purposes, gender consideration is unnecessary. Further studies are needed to investigate the association between VBI and memory dysfunction in early dementia. Copyright © 2013 Elsevier Ltd. All rights reserved.

A fluid-structure interaction model of the internal carotid and ophthalmic arteries for the noninvasive intracranial pressure measurement method.

PubMed

Misiulis, Edgaras; Džiugys, Algis; Navakas, Robertas; Striūgas, Nerijus

2017-05-01

Accurate and clinically safe measurements of intracranial pressure (ICP) are crucial for secondary brain damage prevention. There are two methods of ICP measurement: invasive and noninvasive. Invasive methods are clinically unsafe; therefore, safer noninvasive methods are being developed. One of the noninvasive ICP measurement methods implements the balance principle, which assumes that if the velocity of blood flow in both ophthalmic artery segments - the intracranial (IOA) and extracranial (EOA) - is equal, then the acting ICP on the IOA and the external pressure (Pe) on the EOA are also equal. To investigate the assumption of the balance principle, a generalized computational model incorporating a fluid-structure interaction (FSI) module was created and used to simulate noninvasive ICP measurement by accounting for the time-dependent behavior of the elastic internal carotid (ICA) and ophthalmic (OA) arteries and their interaction with pulsatile blood flow. It was found that the extra balance pressure term, which incorporates the hydrodynamic pressure drop between measurement points, must be added into the balance equation, and the corrections on a difference between the velocity of blood flow in the IOA and EOA must be made, due to a difference in the blood flow rate. Copyright © 2017 Elsevier Ltd. All rights reserved.

Nystagmus-based approach to vertebrobasilar stroke presenting as vertigo without initial neurologic signs.

PubMed

Kim, Min-Beom; Boo, Sung Hyun; Ban, Jae Ho

2013-01-01

We aimed to investigate the clinical courses and common nystagmus of isolated vertigo patients with vertebrobasilar stroke. The patients who presented with isolated acute spontaneous vertigo with spontaneous nystagmus (acute vestibular syndrome) at the Emergency Department were retrospectively analyzed. They were referred to the Otolaryngology Department due to the absence of neurologic signs or even of imaging abnormalities after the initial examination at the Emergency Department. Various clinical features, including presenting symptoms, delayed neurologic signs, the site of infarction, and videonystagmographic (VNG) findings were analyzed. Of the 468 cases of acute vestibular syndrome, 23 (4.9%) cases of radiologically proven vertebrobasilar stroke were identified. Of the 23 patients, 17 (74%) showed aggravation of vertigo or delayed neurologic signs during the admission. In the analysis of VNG, 11 (48%) cases of direction-changing gaze-evoked nystagmus, 7 (30%) cases of fixation failure in the caloric test, 6 (27%) cases of periodic alternating nystagmus, and 4 (17%) cases of atypical head-shaking nystagmus were presented. Stroke occurred in the cerebellum (n=18, 78%), medulla (n=4, 17%), and pons (n=1, 4%). In the early stage of vertebrobasilar stroke, an accurate diagnosis was difficult in the Emergency Department even though a radiologic study was performed, but various VNG abnormalities and delayed neurologic signs could help to diagnose whether the origin is central or not. Copyright © 2013 S. Karger AG, Basel.

High Intracranial Pressure Induced Injury in the Healthy Rat Brain.

PubMed

Dai, Xingping; Bragina, Olga; Zhang, Tongsheng; Yang, Yirong; Rao, Gutti R; Bragin, Denis E; Statom, Gloria; Nemoto, Edwin M

2016-08-01

We recently showed that increased intracranial pressure to 50 mm Hg in the healthy rat brain results in microvascular shunt flow characterized by tissue hypoxia, edema, and increased blood-brain barrier permeability. We now determined whether increased intracranial pressure results in neuronal injury by Fluoro-Jade stain and whether changes in cerebral blood flow and cerebral metabolic rate for oxygen suggest nonnutritive microvascular shunt flow. Intracranial pressure was elevated by a reservoir of artificial cerebrospinal fluid connected to the cisterna magna. Arterial blood gases, cerebral arterial-venous oxygen content difference, and cerebral blood flow by MRI were measured. Fluoro-Jade stain neurons were counted in histologic sections of the right and left dorsal and lateral cortices and hippocampus. University laboratory. Male Sprague Dawley rats. Arterial pressure support if needed by IV dopamine infusion and base deficit corrected by sodium bicarbonate. Fluoro-Jade stain neurons increased 2.5- and 5.5-fold at intracranial pressures of 30 and 50 mm Hg and cerebral perfusion pressures of 57 ± 4 (mean ± SEM) and 47 ± 6 mm Hg, respectively (p < 0.001) (highest in the right and left cortices). Voxel frequency histograms of cerebral blood flow showed a pattern consistent with microvascular shunt flow by dispersion to higher cerebral blood flow at high intracranial pressure and decreased cerebral metabolic rate for oxygen. High intracranial pressure likely caused neuronal injury because of a transition from normal capillary flow to nonnutritive microvascular shunt flow resulting in tissue hypoxia and edema, and it is manifest by a reduction in the cerebral metabolic rate for oxygen.

The effect of chinese herbal medicine Banxia Baizhu Tianma Decoction for the treatment of vertebrobasilar insufficiency vertigo: A systematic review and meta-analysis of randomized controlled trials.

PubMed

Guo, ZhenLang; Su, ZhenNing; Wang, ZhengFei; Luo, XiaoMu; Lai, RenKui

2017-04-01

Banxia Baizhu Tianma Decoction (BBTD) is widely used to treat vertebrobasilar insufficiency vertigo (VBIV) in China, but its efficacy remains largely unexplored. We systemically summarized relevant evidence from randomized controlled trials (RCTs) to assess the therapeutic effect of BBTD. Seven electronic databases were searched for relevant electronic studies published before July 2016. We evaluated RCTs that compared BBTD, anti-vertigo drugs and a combination of BBTD and anti-vertigo drugs. We performed a meta-analysis in accordance with the Cochrane Collaboration criteria. The outcomes were clinical efficacy (CE), blood flow velocity of the vertebrobasilar artery by transcranial Doppler (TCD), and adverse effects. Twenty-seven studies with a total of 2796 patients were identified. Compared with anti-vertigo drugs, BBTD showed slight effects on CE (n=350; RR, 1.09; 95% CI, 1.01-1.18; p=0.03; I 2 =0%); however, BBTD plus anti-vertigo drugs (BPAD) significantly improved the clinical efficacy (n=2446; RR, 1.20; 95% CI, 1.16-1.24; p<0.00001; I 2 =0%) and accelerated the blood flow velocity of the left vertebral artery (LVA) (n=1444; WMD, 5.21cm/s; 95% CI, 3.72-6.70cm/s; p<0.00001; I 2 =91%), the blood flow velocity of the right vertebral artery (RVA) (n=1444; WMD, 5.45cm/s; 95% CI, 4.02-6.88cm/s; p<0.00001; I 2 =89%), and the blood flow velocity of the basilar artery (BA) (n=1872; WMD, 5.20cm/s; 95% CI, 3.86-6.54cm/s; p<0.00001; I 2 =90%). Adverse effects were mentioned in six studies. The current evidence indicates that BPAD is effective for the treatment of VBIV, but the efficacy and safety of BBTD is uncertain because of the limited number of trials and low methodological quality. Hence, high-quality and adequately powered RCTs are warranted. Copyright © 2017 Elsevier Ltd. All rights reserved.

Intracranial placement of a new, compliant guide catheter: technical note.

PubMed

Park, Min S; Stiefel, Michael F; Fiorella, David; Kelly, Michael; McDougall, Cameron G; Albuquerque, Felipe C

2008-09-01

We describe our initial experience with the use of a novel, compliant guide catheter designed for placement within the cranial vasculature in a series of seven patients who were treated for various intracranial pathologies. Seven patients were deemed to have either tortuous supra-aortic, intracranial, and/or extracranial vasculature or to require additional microcatheter support as the result of lesion location. The patients were treated, in part, with the 6-French Neuron delivery catheter (Penumbra, Inc., San Leandro, CA) at the authors' two institutions. The guide catheter was positioned in various distal locations within the intracranial internal carotid artery or external carotid artery. Three patients were treated for unruptured intracranial aneurysms, 2 patients for intracranial atherosclerosis, 1 patient for an arteriovenous malformation, and 1 patient for a pseudoaneurysm. All lesions were successfully treated through a microcatheter advanced in a coaxial fashion through the guide catheter. There were no complications related to the positioning of the catheter. Distal intra- or extracranial placement of a specially designed, compliant guide catheter can be performed safely and may improve access and microcatheter stability in patients with tortuous vessels or difficult-to-reach lesions.

Large Artery Atherosclerotic Occlusive Disease.

PubMed

Cole, John W

2017-02-01

Extracranial or intracranial large artery atherosclerosis is often identified as a potential etiologic cause for ischemic stroke and transient ischemic attack. Given the high prevalence of large artery atherosclerosis in the general population, determining whether an identified atherosclerotic lesion is truly the cause of a patient's symptomatology can be difficult. In all cases, optimally treating each patient to minimize future stroke risk is paramount. Extracranial or intracranial large artery atherosclerosis can be broadly compartmentalized into four distinct clinical scenarios based upon the individual patient's history, examination, and anatomic imaging findings: asymptomatic and symptomatic extracranial carotid stenosis, intracranial atherosclerosis, and extracranial vertebral artery atherosclerotic disease. This review provides a framework for clinicians evaluating and treating such patients. Intensive medical therapy achieves low rates of stroke and death in asymptomatic carotid stenosis. Evidence indicates that patients with severe symptomatic carotid stenosis should undergo carotid revascularization sooner rather than later and that the risk of stroke or death is lower using carotid endarterectomy than with carotid stenting. Specific to stenting, the risk of stroke or death is greatest among older patients and women. Continuous vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy is the mainstay for stroke prevention in the setting of intracranial and vertebral artery origin atherosclerosis. Lifelong vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy are the key elements to reduce future stroke risk in the setting of large artery atherosclerosis. When considering a revascularization procedure for carotid stenosis, patient demographics, comorbidities, and the periprocedural risks of stroke and death should be carefully considered.

Vascular Variations Associated with Intracranial Aneurysms.

PubMed

Orakdogen, Metin; Emon, Selin Tural; Somay, Hakan; Engin, Taner; Is, Merih; Hakan, Tayfun

2017-01-01

To investigate the vascular variations in patients with intracranial aneurysm in circle of Willis. We used the data on 128 consecutive intracranial aneurysm cases. Cerebral angiography images were analyzed retrospectively. Arteries were grouped as anterior cerebral arterial system (ACS), posterior cerebral arterial system (PCS) and middle cerebral arterial system (MCS) for grouping vascular variations. Lateralization, being single/multiple, gender; and also any connection with accompanying aneurysms" number, localization, dimension, whether bleeding/incidental aneurysm has been inspected. Variations were demonstrated in 57.8% of the cases. The most common variation was A1 variation (34.4%). The rate of variations was 36.7%, 24.2% and 10.2% respectively in ACS, PCS and MCS. MCS variations were significantly higher in males. Anterior communicating artery (ACoA) aneurysm observance rates were significantly higher and posterior communicating artery (PCoA) aneurysm and middle cerebral artery (MCA) aneurysm observance rates were significantly lower when compared to "no ACS variation detected" cases. In "PCS variation detected" cases, PCoA aneurysm observance rates and coexistence of multiple variations were significantly higher. The rate of vascular variations in patients with aneurysms was 57.8%. Arterial hypoplasia and aplasia were the most common variations. ACS was the most common region that variations were located in; they were mostly detected on the right side. Coexistence of ACoA aneurysm was higher than PCoA and MCA aneurysms. In the PCS variations group, PCoA aneurysms were the most common aneurysms that accompanying the variation and multiple variations were more common than in the other two groups. The variations in MCS were most common in males.

Large Artery Atherosclerotic Occlusive Disease

PubMed Central

Cole, John W.

2017-01-01

ABSTRACT Purpose of Review: Extracranial or intracranial large artery atherosclerosis is often identified as a potential etiologic cause for ischemic stroke and transient ischemic attack. Given the high prevalence of large artery atherosclerosis in the general population, determining whether an identified atherosclerotic lesion is truly the cause of a patient’s symptomatology can be difficult. In all cases, optimally treating each patient to minimize future stroke risk is paramount. Extracranial or intracranial large artery atherosclerosis can be broadly compartmentalized into four distinct clinical scenarios based upon the individual patient’s history, examination, and anatomic imaging findings: asymptomatic and symptomatic extracranial carotid stenosis, intracranial atherosclerosis, and extracranial vertebral artery atherosclerotic disease. This review provides a framework for clinicians evaluating and treating such patients. Recent Findings: Intensive medical therapy achieves low rates of stroke and death in asymptomatic carotid stenosis. Evidence indicates that patients with severe symptomatic carotid stenosis should undergo carotid revascularization sooner rather than later and that the risk of stroke or death is lower using carotid endarterectomy than with carotid stenting. Specific to stenting, the risk of stroke or death is greatest among older patients and women. Continuous vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy is the mainstay for stroke prevention in the setting of intracranial and vertebral artery origin atherosclerosis. Summary: Lifelong vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy are the key elements to reduce future stroke risk in the setting of large artery atherosclerosis. When considering a revascularization procedure for carotid stenosis, patient demographics, comorbidities, and the periprocedural risks of stroke and

Contribution of intracranial vertebral artery asymmetry to vestibular neuropathy.

PubMed

Chuang, Y M; Chern, C M; Liao, W H; Hsu, L C; Lien, C F; Lirng, J F; Shiao, A S; Ko, J S C

2011-07-01

To test the hypothesis that vertebral artery hypoplasia (VAH) may affect the lateralisation of vestibular neuropathy (VN), probably through haemodynamic effect on the vestibular labyrinth. 69 patients with unilateral VN were examined with a magnetic resonance angiographic (MRA) and caloric test. 50 healthy subjects served as controls. The diagnosis of intracranial VAH was based on MRA if <0.22 cm in VA diameter and a diameter asymmetry index >40%. The authors then correlated the canal paretic side with the VAH side. MRA study revealed 29 VAH (right/left: 23/6) in VN subjects and six VAH in controls (right/left: 5/1). The RR of VAH in VN subjects compared with controls was elevated (RR=2.2; 95% CI 1.8 to 2.8). There was a high accordance rate between the side of VAH and VN. Among 29 patients with unilateral VAH, 65.5% (N=19) had an ipsilateral VN, in which left VAH showed a higher accordance rate (83.3%) than the right side (60.9%). VN subjects with vascular risk factors also had a higher VAH accordance rate (81%) than those without (25%). VAH may serve as a regional haemodynamic negative contributor and impede blood supply to the ipsilateral vestibular labyrinth, contributing to the development of VN, which could be enhanced by atherosclerotic risk factors and the left-sided location.

Extra-intracranial blood shunt mimicking aneurysm rupture: intracranial-pressure-controlled rabbit subarachnoid hemorrhage model.

PubMed

Marbacher, Serge; Sherif, Camillo; Neuschmelting, Volker; Schläppi, Janine-Ai; Takala, Jukka; Jakob, Stephan M; Fandino, Javier

2010-08-30

The achieved degree of delayed cerebral vasospasm (DCVS) in the rabbits most frequently applied cistern magna blood injection model is often mild. The aim of this study was to characterize and evaluate the feasibility of an experimental SAH technique that mimics pathophysiological mechanisms and triggers higher degrees of DCVS. SAH was induced by extracranial-intracranial (EC/IC) shunting of blood from the subclavian artery into the great cerebral cistern. Intracranial pressure (ICP), arterial blood pressure, heart rate, arterial blood gas analysis, and neurological status were monitored throughout the experiments. The magnitude of spasm was determined by comparison of pre-SAH (day 0) and post-SAH (day 3) angiograms and postmortem morphometric analysis of the basilar artery. A total of 13 experiments (SAH, n=11; controls, n=2) were performed. Two animals died after initiation of the EC/IC blood shunt in respiratory arrest. In SAH animals, ICP (baseline: 12+/-1 [mean+/-SD]; peak: 51+/-4; steady-state level: 15+/-2 mm Hg) rose to diastolic blood pressure levels (56+/-3 mm Hg) within 98+/-20s, and fell to a steady state within 186+/-41 s. SAH-induced vasoconstriction of the basilar artery was 53.1+/-2.8% on day 3 compared to baseline (P<0.05) and histology confirmed marked vasoconstriction. This novel technique of SAH induction closely mimics the pathophysiological sequelae of aneurysm rupture and triggers constant higher degrees of delayed cerebral vasospasm than previously described rabbit models. The severity of vasospasm attained offers a unique opportunity to evaluate future therapeutic treatment options. Copyright (c) 2010 Elsevier B.V. All rights reserved.

Intracranial Atherosclerotic Disease

PubMed Central

Khan, Maria; Naqvi, Imama; Bansari, Asha; Kamal, Ayeesha Kamran

2011-01-01

Intracranial atherosclerotic disease (ICAD) is the most common proximate mechanism of ischemic stroke worldwide. Approximately half of those affected are Asians. For diagnosis of ICAD, intra-arterial angiography is the gold standard to identify extent of stenosis. However, noninvasive techniques including transcranial ultrasound and MRA are now emerging as reliable modalities to exclude moderate to severe (50%–99%) stenosis. Little is known about measures for primary prevention of the disease. In terms of secondary prevention of stroke due to intracranial atherosclerotic stenosis, aspirin continues to be the preferred antiplatelet agent although clopidogrel along with aspirin has shown promise in the acute phase. Among Asians, cilostazol has shown a favorable effect on symptomatic stenosis and is of benefit in terms of fewer bleeds. Moreover, aggressive risk factor management alone and in combination with dual antiplatelets been shown to be most effective in this group of patients. Interventional trials on intracranial atherosclerotic stenosis have so far only been carried out among Caucasians and have not yielded consistent results. Since the Asian population is known to be preferentially effected, focused trials need to be performed to establish treatment modalities that are most effective in this population. PMID:21772967

Dynamic Cerebrovascular and Intracranial Pressure Reactivity Assessment of Impaired Cerebrovascular Autoregulation in Intracranial Hypertension.

PubMed

Bragin, Denis E; Statom, Gloria; Nemoto, Edwin M

2016-01-01

We previously suggested that the discrepancy between a critical cerebral perfusion pressure (CPP) of 30 mmHg, obtained by increasing intracranial pressure (ICP), and 60 mmHg, obtained by decreasing arterial pressure, was due to pathological microvascular shunting at high ICP [1], and that the determination of the critical CPP by the static cerebral blood flow (CBF) autoregulation curve is not valid with intracranial hypertension. Here, we demonstrated that induced dynamic ICP reactivity (iPRx), and cerebrovascular reactivity (CVRx) tests accurately identify the critical CPP in the hypertensive rat brain, which differs from that obtained by the static autoregulation curve. Step changes in CPP from 70 to 50 and 30 mmHg were made by increasing ICP using an artificial cerebrospinal fluid reservoir connected to the cisterna magna. At each CPP, a transient 10-mmHg increase in arterial pressure was induced by bolus intravenous dopamine. iPRx and iCVRx were calculated as ΔICP/Δ mean arterial pressure (MAP) and as ΔCBF/ΔMAP, respectively. The critical CPP at high ICP, obtained by iPRx and iCVRx, is 50 mmHg, where compromised capillary flow, transition of blood flow to nonnutritive microvascular shunts, tissue hypoxia, and brain-blood barrier leakage begin to occur, which is higher than the 30 mmHg determined by static autoregulation.

Release of serum S-100β protein and neuron-specific enolase after off-pump coronary artery bypass grafting with and without intracranial and cervical artery stenosis.

PubMed

Tamura, Atsushi; Imamaki, Mizuho; Shimura, Hitoshi; Niitsuma, Yuriko; Miyazaki, Masaru

2011-01-01

The aim of this study was to quantify the amount of brain damage suffered by patients who underwent off-pump coronary artery bypass grafting (OPCAB) in which S-100β protein and neuron-specific enolase were used. Thirty-four patients undergoing scheduled OPCAB were enrolled in the study. The patients were divided into two groups according to the results of their magnetic resonance angiography (MRA) and cervical ultrasonography: 13 patients had cervical or intracranial arterial stenosis (Group A), and 21 patients did not (Group B). Blood samples were collected from the arterial catheters immediately before surgery, upon arrival to the intensive care unit, and 6 and 24 hours after surgery. In blood samples collected from patients upon arrival to the intensive care unit, the maximum concentration of serum s-100β protein in Group A was significantly higher than that of Group B (p = 0.029). Though patients in Group A tended to have higher maximum neuron-specific enolase (NSE) concentrations, there were no significant differences in NSE concentrations at any point between the two groups. Our findings show a correlation between the stenosis detected by MRA or cervical ultrasonography and brain damage after OPCAB.

Endovascular Treatments in Combination with Extracranial-Intracranial Bypass for Complex Intracranial Aneurysms.

PubMed

Sato, Kenichi; Endo, Hidenori; Fujimura, Miki; Endo, Toshiki; Matsumoto, Yasushi; Shimizu, Hiroaki; Tominaga, Teiji

2018-05-01

Although most intracranial aneurysms can be treated with microsurgery or endovascular procedure alone, a subset of aneurysms may require a combined approach. The purpose of this study was to assess the efficacy of endovascular interventions combined with bypass surgery for the treatment of complex intracranial aneurysms. We retrospectively reviewed medical records from a prospectively maintained patient database to identify patients who underwent endovascular treatment of an intracranial aneurysm at our institutes between 2007 and 2017. We recruited patients who received a preplanned combination of endovascular treatment and extracranial-intracranial bypass surgery. Forty-four patients (44 aneurysms) were treated with a combined approach. Twenty-four patients presented with subarachnoid hemorrhage. Treatment strategies included endovascular parent artery occlusion with the bypass surgery to restore cerebral blood flow (n = 12), endovascular trapping with bypass surgery to isolate incorporated branches (n = 12), and intra-aneurysmal coil embolization with bypass surgery to isolate incorporated branches (n = 20). During a mean period of 35.6 months, follow-up catheter angiography was performed in 35 of 44 patients (79.5%) and demonstrated complete aneurysm obliteration in 29 patients (82.9%) and bypass patency in 33 (94.3%). The postoperative aneurysm-related mortality and morbidity rates were 6.8% and 13.6%, respectively. Combined endovascular and surgical bypass procedures are useful for the treatment of complex intracranial aneurysms when conventional surgical or endovascular techniques are not feasible and show acceptable rates of morbidity and mortality. Copyright © 2018 Elsevier Inc. All rights reserved.

Frequency, Risk Factors, and Outcome of Coexistent Small Vessel Disease and Intracranial Arterial Stenosis: Results From the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial.

PubMed

Kwon, Hyung-Min; Lynn, Michael J; Turan, Tanya N; Derdeyn, Colin P; Fiorella, David; Lane, Bethany F; Montgomery, Jean; Janis, L Scott; Rumboldt, Zoran; Chimowitz, Marc I

2016-01-01

Intracranial arterial stenosis (ICAS) and small vessel disease (SVD) may coexist. There are limited data on the frequency and risk factors for coexistent SVD and the effect of SVD on stroke recurrence in patients receiving medical treatment for ICAS. To investigate the frequency and risk factors for SVD and the effect of SVD on stroke recurrence in patients with ICAS. A post hoc analysis of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study, a prospective, multicenter clinical trial. Among 451 participants, 313 (69.4%) had baseline brain magnetic resonance imaging scans read centrally for SVD that was defined by any of the following: old lacunar infarction, grade 2 to 3 on the Fazekas scale (for high-grade white matter hyperintensities), or microbleeds. Patient enrollment in SAMMPRIS began November 25, 2008, and follow-up ended on April 30, 2013. Data analysis for the present study was performed from May 13, 2014, to July 29, 2015. Risk factors in patients with vs without SVD and the association between SVD and other baseline risk factors with any ischemic stroke and ischemic stroke in the territory of the stenotic artery determined using proportional hazards regression. Of 313 patients, 155 individuals (49.5%) had SVD noted on baseline magnetic resonance imaging. Variables that were significantly higher in patients with SVD, reported as mean (SD), included age, 63.5 (10.5) years (P < .001), systolic blood pressure, 149 (22) mm Hg (P < .001), glucose level, 130 (50) mg/dL (P = .03), and lower Montreal Cognitive Assessment scores (median, ≥24 [interquartile range, 20-26]; P = .02).Other significant variables were the number of patients with diabetes mellitus (88 of 155 [56.8%]; P = .003), coronary artery disease (46 [29.7%]; P = .004), stroke before the qualifying event (59 [38.1%]; P < .001), old infarct in the territory of the stenotic intracranial artery (88 [56

Posterior inferior cerebellar artery to posterior inferior cerebellar artery in situ bypass for the treatment of Bow hunter's-type dynamic ischemia in holovertebral dissection.

PubMed

Kan, Peter; Yashar, Parham; Langer, David J; Siddiqui, Adnan H; Levy, Elad I

2012-11-01

Bow hunter's syndrome is a rare cause of vertebrobasilar insufficiency arising from mechanical compression of the vertebral artery (VA) during rotation of the head. Surgical treatment usually involves direct decompression of the VA at the site of compression. We describe what is to our knowledge the first reported case of a posterior inferior cerebellar artery (PICA)-to-PICA in situ bypass for treatment of Bow hunter's-type ischemia in a patient with a VA dissection. The patient was a 41-year-old man who developed disabling symptoms of vertebrobasilar insufficiency after trauma when he rotated his head to the right. Dynamic angiography demonstrated a chronic dissection and stasis of flow in the right VA when his head was rotated to the right, with no obvious site of focal compression. The right VA ended in the PICA and the left VA was of good caliber. A single-photon emission computed tomography study with acetazolamide challenge confirmed brainstem ischemia and poor cerebrovascular reserve. He ultimately underwent a PICA-to-PICA in situ bypass to revascularize his right PICA territory with complete symptom resolution. The PICA-to-PICA in situ bypass is a useful option in the treatment of Bow hunter's-type ischemia in the absence of focal structural compression of the VA or VA stenosis. Copyright © 2012 Elsevier Inc. All rights reserved.

Occipital-posterior cerebral artery bypass via the occipital interhemispheric approach

PubMed Central

Kazumata, Ken; Yokoyama, Yuka; Sugiyama, Taku; Asaoka, Katsuyuki

2013-01-01

Background: The unavailability of the superficial temporal artery (STA) and the location of lesions pose a more technically demanding challenge when compared with conventional STA-superior cerebellar or posterior cerebral artery (PCA) bypass in vascular reconstruction procedures. To describe a case series of patients with cerebrovascular lesions who were treated using an occipital artery (OA) to PCA bypass via the occipital interhemispheric approach. Methods: We retrospectively reviewed three consecutive cases of patients with cerebrovascular lesions who were treated using OA-PCA bypass. Results: OA-PCA bypass was performed via the occipital interhemispheric approach. This procedure included: (1) OA-PCA bypass (n = 1), and combined OA-posterior inferior cerebellar artery and OA-PCA saphenous vein interposition graft bypass (n = 1) in patients with vertebrobasilar ischemia; (2) OA-PCA radial artery interposition graft bypass in one patient with residual PCA aneurysm. Conclusions: OA-PCA bypass represents a useful alternative to conventional STA-SCA or PCA bypass. PMID:23956933

Peri-stent aneurysm formation following a stent implant for stenotic intracranial vertebral artery dissection: a technical report of two cases successfully treated with coil embolization.

PubMed

Ishimaru, Hideki; Nakashima, Kazuaki; Takahata, Hideaki; Matsuoka, Yohjiro

2013-02-01

Although stenting for stenotic vertebral artery dissection (VAD) improves compromised blood flow, subsequent peri-stent aneurysm (PSA) formation is not well-known. We report two cases with PSA successfully treated with coil embolization. Three patients with stenotic intracranial VAD underwent endovascular angioplasty at our institution because they had acute infarction in posterior circulation territory and clinical evidence of hemodynamic insufficiency. In two of three patients balloon angioplasty at first session failed to relieve the stenosis, and a coronary stent was implanted. Angiography immediately after stenting showed no abnormality in case 1 and minimal slit-like projection at proximal portion of the stent in case 2. Angiography obtained 16 months after the stenting revealed PSA in case 1. In case 2, angiography performed 3 months later showed that the projection at proximal portion enlarged and formed an aneurysm outside the stent. Because follow-up angiographies showed growth of the aneurysm in both cases, endovascular aneurysmal embolization was performed. We advanced a microcatheter into the aneurysm through the strut of existing stent and delivered detachable coils into the aneurysm lumen successfully in both cases. The post-procedural course was uneventful, and complete obliteration of aneurysm was confirmed on angiography in both cases. Stenting for stenotic intracranial VAD may result in delayed PSA; therefore, follow-up angiographies would be necessary after stenting for stenotic intracranial arterial dissection. Coil embolization through the stent strut would be a solution for enlarging PSA.

Unruptured intracranial aneurysms in the Familial Intracranial Aneurysm and International Study of Unruptured Intracranial Aneurysms cohorts: differences in multiplicity and location.

PubMed

Mackey, Jason; Brown, Robert D; Moomaw, Charles J; Sauerbeck, Laura; Hornung, Richard; Gandhi, Dheeraj; Woo, Daniel; Kleindorfer, Dawn; Flaherty, Matthew L; Meissner, Irene; Anderson, Craig; Connolly, E Sander; Rouleau, Guy; Kallmes, David F; Torner, James; Huston, John; Broderick, Joseph P

2012-07-01

Familial predisposition is a recognized nonmodifiable risk factor for the formation and rupture of intracranial aneurysms (IAs). However, data regarding the characteristics of familial IAs are limited. The authors sought to describe familial IAs more fully, and to compare their characteristics with a large cohort of nonfamilial IAs. The Familial Intracranial Aneurysm (FIA) study is a multicenter international study with the goal of identifying genetic and other risk factors for formation and rupture of IAs in a highly enriched population. The authors compared the FIA study cohort with the International Study of Unruptured Intracranial Aneurysms (ISUIA) cohort with regard to patient demographic data, IA location, and IA multiplicity. To improve comparability, all patients in the ISUIA who had a family history of IAs or subarachnoid hemorrhage were excluded, as well as all patients in both cohorts who had a ruptured IA prior to study entry. Of 983 patients enrolled in the FIA study with definite or probable IAs, 511 met the inclusion criteria for this analysis. Of the 4059 patients in the ISUIA study, 983 had a previous IA rupture and 657 of the remainder had a positive family history, leaving 2419 individuals in the analysis. Multiplicity was more common in the FIA patients (35.6% vs 27.9%, p<0.001). The FIA patients had a higher proportion of IAs located in the middle cerebral artery (28.6% vs 24.9%), whereas ISUIA patients had a higher proportion of posterior communicating artery IAs (13.7% vs 8.2%, p=0.016). Heritable structural vulnerability may account for differences in IA multiplicity and location. Important investigations into the underlying genetic mechanisms of IA formation are ongoing.

[Embolization of the feeding artery of a meningioma with dangerous vascular anastomosis between the middle meningeal artery and the ophthalmic artery].

PubMed

Meguro, Toshinari; Tomita, Yusuke; Tanabe, Tomoyuki; Muraoka, Kenichiro; Terada, Kinya; Hirotsune, Nobuyuki; Nishino, Shigeki

2013-11-01

Preoperative embolization of intracranial meningioma has been applied to reduce intraoperative blood loss and to facilitate microsurgical removal of a tumor. It is well known that one of the reasons of the neurological risk of embolization is due to dangerous anastomosis between the extracranial and the intracranial arteries. One of the most known and dangerous case of anastomosis is between the middle meningeal artery to the ophthalmic artery. A 48-year-old woman underwent preoperative embolization of a large right middle cranial fossa meningioma. The right external carotid angiogram showed that the tumor was fed by the right middle meningeal artery and there was no branch to the right orbital region. The right internal carotid angiogram showed that the right ophthalmic artery originated from the right internal carotid artery and there was no branch to the tumor. The selective angiogram of the anterior branch of the middle meningeal artery disclosed the anastomosis to the right ophthalmic artery. Following embolization of the anterior branch of the middle meningeal artery, the patient underwent embolization of the main feeding branch of the meningioma. She successfully underwent surgical removal of the tumor without any blood transfusion and was discharged without neurological deficit. In addition, to avoid complication in embolization of the feeding artery of a skull base meningioma, clinicians must be aware of the dangerous anastomosis between the middle meningeal artery and the ophthalmic artery, even if conventional external and internal carotid angiograms do not show any anastomosis.

Short-duration hypothermia after ischemic stroke prevents delayed intracranial pressure rise.

PubMed

Murtha, L A; McLeod, D D; McCann, S K; Pepperall, D; Chung, S; Levi, C R; Calford, M B; Spratt, N J

2014-07-01

Intracranial pressure elevation, peaking three to seven post-stroke is well recognized following large strokes. Data following small-moderate stroke are limited. Therapeutic hypothermia improves outcome after cardiac arrest, is strongly neuroprotective in experimental stroke, and is under clinical trial in stroke. Hypothermia lowers elevated intracranial pressure; however, rebound intracranial pressure elevation and neurological deterioration may occur during rewarming. (1) Intracranial pressure increases 24 h after moderate and small strokes. (2) Short-duration hypothermia-rewarming, instituted before intracranial pressure elevation, prevents this 24 h intracranial pressure elevation. Long-Evans rats with two hour middle cerebral artery occlusion or outbred Wistar rats with three hour middle cerebral artery occlusion had intracranial pressure measured at baseline and 24 h. Wistars were randomized to 2·5 h hypothermia (32·5°C) or normothermia, commencing 1 h after stroke. In Long-Evans rats (n = 5), intracranial pressure increased from 10·9 ± 4·6 mmHg at baseline to 32·4 ± 11·4 mmHg at 24 h, infarct volume was 84·3 ± 15·9 mm(3) . In normothermic Wistars (n = 10), intracranial pressure increased from 6·7 ± 2·3 mmHg to 31·6 ± 9·3 mmHg, infarct volume was 31·3 ± 18·4 mm(3) . In hypothermia-treated Wistars (n = 10), 24 h intracranial pressure did not increase (7·0 ± 2·8 mmHg, P < 0·001 vs. normothermia), and infarct volume was smaller (15·4 ± 11·8 mm(3) , P < 0·05). We saw major intracranial pressure elevation 24 h after stroke in two rat strains, even after small strokes. Short-duration hypothermia prevented the intracranial pressure rise, an effect sustained for at least 18 h after rewarming. The findings have potentially important implications for design of future clinical trials. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke

Intracranial stenosis in cognitive impairment and dementia.

PubMed

Hilal, Saima; Xu, Xin; Ikram, M Kamran; Vrooman, Henri; Venketasubramanian, Narayanaswamy; Chen, Christopher

2017-06-01

Intracranial stenosis is a common vascular lesion observed in Asian and other non-Caucasian stroke populations. However, its role in cognitive impairment and dementia has been under-studied. We, therefore, examined the association of intracranial stenosis with cognitive impairment, dementia and their subtypes in a memory clinic case-control study, where all subjects underwent detailed neuropsychological assessment and 3 T neuroimaging including three-dimensional time-of-flight magnetic resonance angiography. Intracranial stenosis was defined as ≥50% narrowing in any of the intracranial arteries. A total of 424 subjects were recruited of whom 97 were classified as no cognitive impairment, 107 as cognitive impairment no dementia, 70 vascular cognitive impairment no dementia, 121 Alzheimer's Disease, and 30 vascular dementia. Intracranial stenosis was associated with dementia (age/gender/education - adjusted odds ratios (OR): 4.73, 95% confidence interval (CI): 1.93-11.60) and vascular cognitive impairment no dementia (OR: 3.98, 95% CI: 1.59-9.93). These associations were independent of cardiovascular risk factors and MRI markers. However, the association with Alzheimer's Disease and vascular dementia became attenuated in the presence of white matter hyperintensities. Intracranial stenosis is associated with vascular cognitive impairment no dementia independent of MRI markers. In Alzheimer's Disease and vascular dementia, this association is mediated by cerebrovascular disease. Future studies focusing on perfusion and functional markers are needed to determine the pathophysiological mechanism(s) linking intracranial stenosis and cognition so as to identify treatment strategies.

Apollo stent for symptomatic atherosclerotic intracranial stenosis: study results.

PubMed

Jiang, W-J; Xu, X-T; Jin, M; Du, B; Dong, K-H; Dai, J-P

2007-05-01

A recent trial shows an 8.3 per 100-patient-years' ischemic stroke rate in the territory of the intracranial stenotic artery, despite aspirin treatment. Our aim was to prospectively study the feasibility and outcome of a new intracranial balloon-expandable Apollo stent for symptomatic atherosclerotic intracranial stenosis (SAIS). Forty-six patients (41 men and 5 women; median, 54 years of age) with forty-eight >or=50% SAISs were enrolled. Procedural feasibility was evaluated by stent success (residual stenosis artery territory, including any stroke and death within 30 days. Forty-four lesions (91.7%) obtained stent success within a median procedural time of 50.6 minutes. Severe tortuosity correlated with stent failure. Three patients (6.5%, 3/46) had minor strokes within 30 days. All patients were available for follow-up (46 had 30-day follow-up, 45 had 6-month follow-up, 44 had 12- and 18-month follow-up, and 24 had follow-up of >or=24 months), which varied from 1 month to 30.7 months (median, 23.9 months). After 30 days, 1 patient (2.2%, 1/46) developed minor stroke in the target-lesion artery territory at 6.7 months. Primary end point rate was 4.3 per 100 patient years. Angiographic follow-up was performed in 25 patients. Seven restenoses (28%, 7/25) were detected, 1 of which was symptomatic. Angioplasty with the Apollo stent for symptomatic atherosclerotic intracranial stenosis is feasible. Severe tortuosity is an independent predictor of stent failure. Our clinical outcome seems to compare favorably with results of aspirin therapy, but the restenotic rate was high.

Workflow Optimization in Vertebrobasilar Occlusion

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kamper, Lars, E-mail: lars.kamper@helios-kliniken.de; Meyn, Hannes; Rybacki, Konrad

2012-06-15

Objective: In vertebrobasilar occlusion, rapid recanalization is the only substantial means to improve the prognosis. We introduced a standard operating procedure (SOP) for interventional therapy to analyze the effects on interdisciplinary time management. Methods: Intrahospital time periods between hospital admission and neuroradiological intervention were retrospectively analyzed, together with the patients' outcome, before (n = 18) and after (n = 20) implementation of the SOP. Results: After implementation of the SOP, we observed statistically significant improvement of postinterventional patient neurological status (p = 0.017). In addition, we found a decrease of 5:33 h for the mean time period from hospital admissionmore » until neuroradiological intervention. The recanalization rate increased from 72.2% to 80% after implementation of the SOP. Conclusion: Our results underscore the relevance of SOP implementation and analysis of time management for clinical workflow optimization. Both may trigger awareness for the need of efficient interdisciplinary time management. This could be an explanation for the decreased time periods and improved postinterventional patient status after SOP implementation.« less

The population-based Barcelona-Asymptomatic Intracranial Atherosclerosis Study (ASIA): rationale and design

PubMed Central

2011-01-01

Background Large-artery intracranial atherosclerosis may be the most frequent cause of ischemic stroke worldwide. Traditional approaches have attempted to target the disease when it is already symptomatic. However, early detection of intracranial atherosclerosis may allow therapeutic intervention while the disease is still asymptomatic. The prevalence and natural history of asymptomatic intracranial atherosclerosis in Caucasians remain unclear. The aims of the Barcelona-ASymptomatic Intracranial Atherosclerosis (ASIA) study are (1) to determine the prevalence of ASIA in a moderate-high vascular risk population, (2) to study its prognostic impact on the risk of suffering future major ischemic events, and (3) to identify predictors of the development, progression and clinical expression of this condition. Methods/Design Cross-over and cohort, population-based study. A randomly selected representative sample of 1,503 subjects with a mild-moderate-high vascular risk (as defined by a REGICOR score ≥ 5%) and with neither a history of cerebrovascular nor ischemic heart disease will be studied. At baseline, all individuals will undergo extracranial and transcranial Color-Coded Duplex (TCCD) ultrasound examinations to detect presence and severity of extra and intracranial atherosclerosis. Intracranial stenoses will be assessed by magnetic resonance angiography (MRA). Clinical and demographic variables will be recorded and blood samples will be drawn to investigate clinical, biological and genetic factors associated with the presence of ASIA. A long-term clinical and sonographic follow-up will be conducted thereafter to identify predictors of disease progression and of incident vascular events. Discussion The Barcelona-ASIA is a population-based study aiming to evaluate the prevalence and clinical importance of asymptomatic intracranial large-artery atherosclerosis in Caucasians. The ASIA project may provide a unique scientific resource to better understand the dynamics of

The population-based Barcelona-Asymptomatic Intracranial Atherosclerosis Study (ASIA): rationale and design.

PubMed

López-Cancio, Elena; Dorado, Laura; Millán, Mónica; Reverté, Silvia; Suñol, Anna; Massuet, Anna; Mataró, María; Galán, Amparo; Alzamora, Maite; Pera, Guillem; Torán, Pere; Dávalos, Antoni; Arenillas, Juan F

2011-02-17

Large-artery intracranial atherosclerosis may be the most frequent cause of ischemic stroke worldwide. Traditional approaches have attempted to target the disease when it is already symptomatic. However, early detection of intracranial atherosclerosis may allow therapeutic intervention while the disease is still asymptomatic. The prevalence and natural history of asymptomatic intracranial atherosclerosis in Caucasians remain unclear. The aims of the Barcelona-ASymptomatic Intracranial Atherosclerosis (ASIA) study are (1) to determine the prevalence of ASIA in a moderate-high vascular risk population, (2) to study its prognostic impact on the risk of suffering future major ischemic events, and (3) to identify predictors of the development, progression and clinical expression of this condition. Cross-over and cohort, population-based study. A randomly selected representative sample of 1,503 subjects with a mild-moderate-high vascular risk (as defined by a REGICOR score ≥ 5%) and with neither a history of cerebrovascular nor ischemic heart disease will be studied. At baseline, all individuals will undergo extracranial and transcranial Color-Coded Duplex (TCCD) ultrasound examinations to detect presence and severity of extra and intracranial atherosclerosis. Intracranial stenoses will be assessed by magnetic resonance angiography (MRA). Clinical and demographic variables will be recorded and blood samples will be drawn to investigate clinical, biological and genetic factors associated with the presence of ASIA. A long-term clinical and sonographic follow-up will be conducted thereafter to identify predictors of disease progression and of incident vascular events. The Barcelona-ASIA is a population-based study aiming to evaluate the prevalence and clinical importance of asymptomatic intracranial large-artery atherosclerosis in Caucasians. The ASIA project may provide a unique scientific resource to better understand the dynamics of intracranial atherosclerosis from

Increased intracranial pressure elicits hypertension, increased sympathetic activity, electrocardiographic abnormalities and myocardial damage in rats.

PubMed

Shanlin, R J; Sole, M J; Rahimifar, M; Tator, C H; Factor, S M

1988-09-01

Intracranial pressure was increased in 59 rats by inflating a subdural balloon to a total mass volume of 0.3 ml. The increase in intracranial pressure ranged from 75 to greater than 500 mm Hg. With few exceptions, mean arterial pressure increased to as high as 227 mm Hg during the increase in intracranial pressure. Significant increases in plasma catecholamines, major electrocardiographic changes and a considerably shortened survival time were observed only in the rats that demonstrated an increase in mean arterial pressure greater than 50 mm Hg. A perfusion study with liquid silicone rubber (Microfil) revealed dilated irregular myocardial vessels with areas of focal constriction consistent with microvascular spasm. Histologic examination of the myocardium revealed widespread patches of contraction band necrosis and occasional contraction bands in the smooth muscle media of large coronary arteries. These observations suggest that myocardial damage after suddenly increased intracranial pressure resulted both from exposure to toxic levels of catecholamines and from myocardial reperfusion. Extension of these studies to humans suggests that a detailed assessment of myocardial function should be performed in victims of severe brain injury. Myocardial dysfunction may be a major determinant of the patient's prognosis or may render the heart unsuitable for transplantation.

Development of a quantitative intracranial vascular features extraction tool on 3D MRA using semiautomated open-curve active contour vessel tracing.

PubMed

Chen, Li; Mossa-Basha, Mahmud; Balu, Niranjan; Canton, Gador; Sun, Jie; Pimentel, Kristi; Hatsukami, Thomas S; Hwang, Jenq-Neng; Yuan, Chun

2018-06-01

To develop a quantitative intracranial artery measurement technique to extract comprehensive artery features from time-of-flight MR angiography (MRA). By semiautomatically tracing arteries based on an open-curve active contour model in a graphical user interface, 12 basic morphometric features and 16 basic intensity features for each artery were identified. Arteries were then classified as one of 24 types using prediction from a probability model. Based on the anatomical structures, features were integrated within 34 vascular groups for regional features of vascular trees. Eight 3D MRA acquisitions with intracranial atherosclerosis were assessed to validate this technique. Arterial tracings were validated by an experienced neuroradiologist who checked agreement at bifurcation and stenosis locations. This technique achieved 94% sensitivity and 85% positive predictive values (PPV) for bifurcations, and 85% sensitivity and PPV for stenosis. Up to 1,456 features, such as length, volume, and averaged signal intensity for each artery, as well as vascular group in each of the MRA images, could be extracted to comprehensively reflect characteristics, distribution, and connectivity of arteries. Length for the M1 segment of the middle cerebral artery extracted by this technique was compared with reviewer-measured results, and the intraclass correlation coefficient was 0.97. A semiautomated quantitative method to trace, label, and measure intracranial arteries from 3D-MRA was developed and validated. This technique can be used to facilitate quantitative intracranial vascular research, such as studying cerebrovascular adaptation to aging and disease conditions. Magn Reson Med 79:3229-3238, 2018. © 2017 International Society for Magnetic Resonance in Medicine. © 2017 International Society for Magnetic Resonance in Medicine.

Basilar artery angulation in association with aging and pontine lacunar infarction: a multicenter observational study.

PubMed

Jeong, Seul-Ki; Lee, Ju-Hee; Nam, Do-Hyun; Kim, Joon-Tae; Ha, Yeon Soo; Oh, Sun-Young; Park, Se-Hyoung; Lee, Sang Hyuk; Hur, Nahmkeon; Kwak, Hyo-Sung; Chung, Gyung-Ho

2015-01-01

Deep pontine lacunar infarction (DPLI) not involving the basal pial surface of the medial part of the pons, is known to be a small vessel disease in the territory of the basilar artery (BA). In the present study, we examined whether morphological features of the BA differ in individuals with an advanced age and may be associated with DPLI. This study included 338 healthy subjects and 78 patients with DPLI treated at the stroke centers of three university hospitals in Korea. Time-Of-Flight magnetic resonance angiographic images were transported to a central lab and analyzed blind to obtain the clinical data. For the quantitative analysis, the BA was projected two-dimensionally in the anteroposterior and lateral views and perceived as triangles of the vertebrobasilar junction, angulation point and BA division. The angles and triangular areas were summated into angulation indexes and used to quantify the degree of BA tortuosity. The BA showed a more acute angle at the angulation point in the elderly patients than in the healthy subjects. Compared to the healthy subjects, the DPLI patients exhibited significantly larger angles at the vertebrobasilar junction, in addition to the acute angles noted at the angulation point. A unit increase in the BA angle indexes at the vertebrobasilar junction and angulation points for DPLI was found to have an odds ratio of 1.15 (95% confidence interval, 1.05-1.26) and 0.95 (95% CI, 0.91-0.99), respectively, even after adjusting for potential confounders. The angulation point of the BA becomes more acute in elderly individuals. In this study, the vertebrobasilar junction showed a larger angle in the patients with DPLI than in the healthy controls.

[Effects of xenon anesthesia on cerebral blood flow in neurosurgical patients without intracranial hypertension].

PubMed

Rylova, A V; Beliaev, A Iu; Lubnin, A Iu

2013-01-01

Among anesthetic agents used in neurosurgery xenon appears to be the most advantageous. It preserves arterial blood pressure, assures rapid recovery and neuroprotection. But the data is lacking on xenon effect upon cerebral blood flow under anesthetic conditions. We measured flow velocity in middle cerebral artery in neurosurgical patients without intracranial hypertension during closed circuit xenon anesthesia comparing propofol and xenon effect in the same patients. In our study xenon didn't seem to induce clinically relevant changes in cerebral blood flow and preserved cerebral vascular reactivity thus proving its safety in patients without intracranial hypertension.

Combined Angio-Seal™ and stenting rescue treatment in a case of iatrogenic common carotid artery dissection during direct puncture for ruptured intracranial aneurysm embolization: a technical note.

PubMed

Iosif, Christina; Clarençon, Frédéric; Di Maria, Federico; Law-Ye, Bruno; Le Jean, Lise; Capelle, Laurent; Chiras, Jacques; Sourour, Nader

2013-05-01

Direct puncture may offer an alternative access for embolization of intracranial aneurysms in patients presenting with tortuous vessels. Nevertheless, major complications such as compressive hematoma and arterial dissection can occur with this technique. A tight common carotid artery (CCA) dissection was seen secondary to direct puncture in a 72-year-old patient who presented with a ruptured anterior communicating artery (ACom) aneurysm. After regular coiling of the aneurysm and using a femoral approach, an Angio-Seal™ device (St Jude Medical, Saint Paul, MN, USA) was placed and a carotid wallstent (Stryker Neurovascular, Fremont, CA, USA) successfully deployed at the dissected CCA, which was followed by good clinical and angiographic outcomes. A combined rescue technique combining Angio-Seal insertion and stent deployment was safe and effective for managing iatrogenic carotid artery dissection. Copyright © 2013. Published by Elsevier Masson SAS.

Final Results of Cilostazol-Aspirin Therapy against Recurrent Stroke with Intracranial Artery Stenosis (CATHARSIS).

PubMed

Uchiyama, Shinichiro; Sakai, Nobuyuki; Toi, Sono; Ezura, Masayuki; Okada, Yasushi; Takagi, Makoto; Nagai, Yoji; Matsubara, Yoshihiro; Minematsu, Kazuo; Suzuki, Norihiro; Tanahashi, Norio; Taki, Waro; Nagata, Izumi; Matsumoto, Masayasu

2015-01-01

To compare the effect of cilostazol plus aspirin versus aspirin alone on the progression of intracranial arterial stenosis (IAS), and to compare ischemic and hemorrhagic events in patients with symptomatic IAS, an investigator-driven, nationwide multicenter cooperative randomized controlled trial (CATHARSIS; ClinicalTrials.gov Identifier 00333164) was conducted. 165 noncardioembolic ischemic stroke patients with >50% stenosis in the responsible intracranial artery after 2 weeks to 6 months from the onset were randomly allocated to receive either cilostazol 200 mg/day plus aspirin 100 mg/day (n = 83, CA group) or aspirin 100 mg/day alone (n = 82, A group). The primary endpoint was the progression of IAS on magnetic resonance angiography at 2 years after randomization. Secondary endpoints were any vascular events, any cause of death, serious adverse events, new silent brain infarcts, and worsening of the modified Rankin Scale score. Progression of IAS was observed in 9.6% of the CA group patients and in 5.6% of the A group patients, with no significant intergroup difference (p = 0.53). The incidence of the secondary endpoints tended to be lower in the CA group compared with the A group, although the differences were not significant. By using exploratory logistic regression analysis adjusted for patient background characteristics, it was shown that the risk for certain combinations of secondary endpoints was lower in the CA group than in the A group [all vascular events and silent brain infarcts: odds ratio (OR) = 0.37, p = 0.04; stroke and silent brain infarcts: OR = 0.34, p = 0.04; all vascular events, worsening of modified Rankin Scale scores and silent brain infracts: OR = 0.41, p = 0.03]. Major hemorrhage was observed in 4 patients of the CA group and in 3 of the A group. Progression of IAS during the 2-year observation period appears to be less frequent than previously reported in stroke patients on antiplatelet agents after the acute phase, which could be due

Cryptogenic Stroke and Nonstenosing Intracranial Calcified Atherosclerosis.

PubMed

Kamel, Hooman; Gialdini, Gino; Baradaran, Hediyeh; Giambrone, Ashley E; Navi, Babak B; Lerario, Michael P; Min, James K; Iadecola, Costantino; Gupta, Ajay

2017-04-01

Because some cryptogenic strokes may result from large-artery atherosclerosis that goes unrecognized as it causes <50% luminal stenosis, we compared the prevalence of nonstenosing intracranial atherosclerotic plaques ipsilateral to cryptogenic cerebral infarcts versus the unaffected side using imaging biomarkers of calcium burden. In a prospective stroke registry, we identified patients with cerebral infarction limited to the territory of one internal carotid artery (ICA). We included patients with stroke of undetermined etiology and, as controls, patients with cardioembolic stroke. We used noncontrast computed tomography to measure calcification in both intracranial ICAs, including qualitative calcium scoring and quantitative scoring utilizing the Agatston-Janowitz (AJ) calcium scoring. Within subjects, the Wilcoxon signed-rank sum test for nonparametric paired data was used to compare the calcium burden in the ICA upstream of the infarction versus the ICA on the unaffected side. We obtained 440 calcium measures from 110 ICAs in 55 patients. Among 34 patients with stroke of undetermined etiology, we found greater calcium in the ICA ipsilateral to the infarction (mean Modified Woodcock Visual Scale score, 6.7 ± 4.6) compared with the contralateral side (5.4 ± 4.1) (P = .005). Among 21 patients with cardioembolic stroke, we found no difference in calcium burden ipsilateral to the infarction (6.7 ± 5.9) versus the contralateral side (7.3 ± 6.3) (P = .13). The results were similar using quantitative calcium measurements, including the AJ calcium scores. In patients with strokes of undetermined etiology, the burden of calcified intracranial large-artery plaque was associated with downstream cerebral infarction. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Differential blood flow responses to CO2 in human internal and external carotid and vertebral arteries

PubMed Central

Sato, Kohei; Sadamoto, Tomoko; Hirasawa, Ai; Oue, Anna; Subudhi, Andrew W; Miyazawa, Taiki; Ogoh, Shigehiko

2012-01-01

Arterial CO2 serves as a mediator of cerebral blood flow (CBF), and its relative influence on the regulation of CBF is defined as cerebral CO2 reactivity. Our previous studies have demonstrated that there are differences in CBF responses to physiological stimuli (i.e. dynamic exercise and orthostatic stress) between arteries in humans. These findings suggest that dynamic CBF regulation and cerebral CO2 reactivity may be different in the anterior and posterior cerebral circulation. The aim of this study was to identify cerebral CO2 reactivity by measuring blood flow and examine potential differences in CO2 reactivity between the internal carotid artery (ICA), external carotid artery (ECA) and vertebral artery (VA). In 10 healthy young subjects, we evaluated the ICA, ECA, and VA blood flow responses by duplex ultrasonography (Vivid-e, GE Healthcare), and mean blood flow velocity in middle cerebral artery (MCA) and basilar artery (BA) by transcranial Doppler (Vivid-7, GE healthcare) during two levels of hypercapnia (3% and 6% CO2), normocapnia and hypocapnia to estimate CO2 reactivity. To characterize cerebrovascular reactivity to CO2, we used both exponential and linear regression analysis between CBF and estimated partial pressure of arterial CO2, calculated by end-tidal partial pressure of CO2. CO2 reactivity in VA was significantly lower than in ICA (coefficient of exponential regression 0.021 ± 0.008 vs. 0.030 ± 0.008; slope of linear regression 2.11 ± 0.84 vs. 3.18 ± 1.09% mmHg−1: VA vs. ICA, P < 0.01). Lower CO2 reactivity in the posterior cerebral circulation was persistent in distal intracranial arteries (exponent 0.023 ± 0.006 vs. 0.037 ± 0.009; linear 2.29 ± 0.56 vs. 3.31 ± 0.87% mmHg−1: BA vs. MCA). In contrast, CO2 reactivity in ECA was markedly lower than in the intra-cerebral circulation (exponent 0.006 ± 0.007; linear 0.63 ± 0.64% mmHg−1, P < 0.01). These findings indicate that vertebro-basilar circulation has lower CO2 reactivity than

Complexity of intracranial pressure correlates with outcome after traumatic brain injury

PubMed Central

Lu, Cheng-Wei; Czosnyka, Marek; Shieh, Jiann-Shing; Smielewska, Anna; Pickard, John D.

2012-01-01

This study applied multiscale entropy analysis to investigate the correlation between the complexity of intracranial pressure waveform and outcome after traumatic brain injury. Intracranial pressure and arterial blood pressure waveforms were low-pass filtered to remove the respiratory and pulse components and then processed using a multiscale entropy algorithm to produce a complexity index. We identified significant differences across groups classified by the Glasgow Outcome Scale in intracranial pressure, pressure-reactivity index and complexity index of intracranial pressure (P < 0.0001; P = 0.001; P < 0.0001, respectively). Outcome was dichotomized as survival/death and also as favourable/unfavourable. The complexity index of intracranial pressure achieved the strongest statistical significance (F = 28.7; P < 0.0001 and F = 17.21; P < 0.0001, respectively) and was identified as a significant independent predictor of mortality and favourable outcome in a multivariable logistic regression model (P < 0.0001). The results of this study suggest that complexity of intracranial pressure assessed by multiscale entropy was significantly associated with outcome in patients with brain injury. PMID:22734128

Intracranial vascular stenosis and occlusion: Diagnostic accuracy of three-dimensional, fourier transform, time-of-flight MR angiography

DOE Office of Scientific and Technical Information (OSTI.GOV)

Korogi, Yukunori; Takahashi, Mutsumasa; Mabuchi, Nobuhisa

1994-10-01

To assess the accuracy of three-dimensional, Fourier transform, time-of-flight magnetic resonance (MR) angiography in the detection of intracranial steno-occlusive diseases. One hundred thirty-one patients (62 male and 69 female patients, aged 6-77 years [mean, 53 years 8 months]) underwent MR and conventional angiography for evaluation of possible intracranial vascular disease. A total of 502 arteries were assessed. Eight projections and a collapsed image postprocessed by means of a maximum-intensity projection algorithm were reviewed by five observers in a blinded manner, with conventional angiography as the standard. A total of 32 steno-occlusive lesions were available for review. Receiver operating characteristic analysismore » from the pooled data revealed overall sensitivities of 85% and 88% and specificities of 96% and 97% for the internal carotid artery and the middle cerebral artery, respectively. MR angiography is useful as the primary diagnostic tool for evaluating suspected intracranial steno-occlusive disease. 22 refs., 7 figs., 5 tabs.« less

Prevalence of middle cerebral artery stenosis in asymptomatic subjects of more than 40 years age group: a transcranial Doppler study.

PubMed

Sada, Sujay; Reddy, Yugandhar; Rao, Sampath; Alladi, Suvarna; Kaul, Subash

2014-01-01

Middle cerebral artery (MCA) disease is the most common vascular lesion in stroke. Transcranial Doppler (TCD) is a non-invasive bedside screening method for assessing cerebral blood flow. To investigate the prevalence of MCA stenosis in asymptomatic but high-risk individuals for stroke. Prospective study between December 2011 and December 2013. Vascular risk factors considered included: hypertension (HTN), diabetes mellitus, smoking, alcohol consumption, coronary artery disease (CAD), peripheral vascular disease (PVD), hypercholesterolemia and obesity. TCD was performed with portable machine through the temporal windows by use of a standardized protocol. Of the 427 subjects, 374 were analyzed; males 264 (70.6%) and females 110 (29.4%). Mean age was 54.2 ± 7.6 years. The frequency of the risk factors was: HTN 287 (76.7%), diabetes 220 (58.8%), CAD 120 (32.1%), hypercholesterolemia 181 (48.4%), smoking 147 (39.3%), alcohol 99 (26.5%), obesity 198 (52.9%) and PVD 8 (2.1%). Of the 374 subjects, 27 (7.2%) had intracranial arterial stenosis and the rest had normal intracranial arteries. On univariate analysis, subjects with higher age, HTN, CAD, smoking and hypercholesterolemia had higher risk of having intracranial arterial stenosis (P < 0.05). Multivariate analysis showed HTN and CAD are independent risk factors for intracranial arterial stenosis. Overall prevalence of intracranial arterial stenosis is 7.2% in high-risk population sample from Hyderabad in South India. HTN and CAD are independent risk factors for the development of intracranial arterial stenosis.

Dural arteriovenous fistulas as a cause of intracranial hypertension due to impairment of cranial venous outflow

PubMed Central

Cognard, C.; Casasco, A.; Toevi, M.; Houdart, E.; Chiras, J.; Merland, J.

1998-01-01

OBJECTIVES—A retrospective study was carried out on 13 patients with intracranial dural arteriovenous fistulas (DAVFs) who presented with isolated or associated signs of intracranial hypertension.
METHODS—Nine patients presented with symptoms of intracranial hypertension at the time of diagnosis. Ocular fundoscopy available in 12 patients showed bilateral papilloedema in eight and optic disk atrophy in four. Clinical evolution was particularly noticeable in five patients because of chronic (two patients) or acute (after lumbar shunting or puncture: three patients, one death) tonsillar herniation.
RESULTS—Two patients had a type I fistula (drainage into a sinus, with a normal antegrade flow direction). The remaining 11 had type II fistulas (drainage into a sinus, with abnormal retrograde venous drainage into sinuses or cortical veins). Stenosis or thrombosis of the sinus(es) distal to the fistula was present in five patients. The cerebral venous drainage was abnormal in all patients.
CONCLUSION—Type II (and some type I) DAVFs may present as isolated intracranial hypertension mimicking benign intracranial hypertension. Normal cerebral angiography should be added as a fifth criterion of benign intracranial hypertension. The cerebral venous drainage pattern must be carefully studied by contralateral carotid and vertebral artery injections to correctly evaluate the impairment of the cerebral venous outflow. Lumbar CSF diversion (puncture or shunting) may induce acute tonsillar herniation and should be avoided absolutely. DAVF may induce intracranial hypertension, which has a poor long term prognosis and may lead to an important loss of visual acuity and chronic tonsillar herniation. Consequently, patients with intracranial hypertension must be treated, even agressively, to obliterate the fistula or at least to reduce the arterial flow and to restore a normal cerebral venous drainage. The endovascular treatment may associate arterial or transvenous

Design of the stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis trial.

PubMed

Chimowitz, Marc I; Lynn, Michael J; Turan, Tanya N; Fiorella, David; Lane, Bethany F; Janis, Scott; Derdeyn, Colin P

2011-01-01

Patients with recent transient ischemic attack (TIA) or stroke caused by 70% to 99% stenosis of a major intracranial artery are at high risk of recurrent stroke on usual medical management, suggesting the need for alternative therapies for this disease. The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial is an ongoing, randomized, multicenter, 2-arm trial that will determine whether intracranial angioplasty and stenting adds benefit to aggressive medical management alone for preventing the primary endpoint (any stroke or death within 30 days after enrollment or after any revascularization procedure of the qualifying lesion during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days) during a mean follow-up of 2 years in patients with recent TIA or stroke caused by 70% to 99% stenosis of a major intracranial artery. Aggressive medical management in both arms consists of aspirin 325 mg per day, clopidogrel 75 mg per day for 90 days after enrollment, intensive risk factor management primarily targeting systolic blood pressure <140 mm Hg (<130 mm Hg in diabetics) and low density cholesterol <70 mg/dL, and a lifestyle modification program. The sample size required to detect a 35% reduction in the rate of the primary endpoint from angioplasty and stenting based on the log-rank test with an alpha of 0.05, 80% power, and adjusting for a 2% loss to follow-up and 5% crossover from the medical to the stenting arm is 382 patients per group. Enrollment began in November 2008 and 451 patients have been enrolled as of March 31, 2011. This is the first randomized stroke prevention trial to compare angioplasty and stenting with medical therapy in patients with intracranial arterial stenosis and to incorporate intensive management of multiple risk factors and a lifestyle modification program in the study design. Hopefully, the results of the trial will lead to more effective therapy for

High prevalence of intracranial aneurysms in patients with aortic dissection or aneurysm: feasibility of extended aorta CT angiography with involvement of intracranial arteries.

PubMed

Lee, Dahye; Ahn, Sung Jun; Cho, Eun-Suk; Kim, Yong Bae; Song, Suk-Won; Jung, Woo Sang; Suh, Sang Hyun

2017-10-01

Previous studies have suggested a higher prevalence of intracranial aneurysms (IAs) in patients with aortic aneurysms (AAs). To carry out a preliminary study to evaluate the prevalence of IAs in these patients and the diagnostic feasibility of extended aorta CT angiography (CTA), including intracranial arteries as well as the aorta. We retrospectively reviewed all patients with a clinical diagnosis of AA or aortic dissection (AD) who had undergone aorta CTA as well as MR angiography, CTA, and/or DSA of the brain between 2009 and 2014. Since 2012, the extended aorta CTA protocol has been applied in these patients. Characteristics of IAs were classified with baseline clinical data. For quantitative and qualitative assessment by two independent raters, brain images obtained by extended aorta CTA and brain CTA were compared. The radiation dose of the two aorta protocols was compared. The prevalence of IA was 22.2% (35/158). All IAs were detected by extended aorta CTA, except one small aneurysm (<3 mm). The mean vascular attenuation value between brain images showed no difference (p=0.83), but the contrast-to-noise ratio was significantly lower in extended aorta CTA (p<0.001). In qualitative assessment, the interobserver agreement was substantial (k=0.79). For the radiation dose, the dose-length product of the extended aorta CTA increased with increment of the scan range (p=0.048). With a high prevalence of IAs in patients with ADs or AAs, extended aorta CTA could be used to evaluate aorta disease and IA in a single session. However, further prospective studies are needed to prove efficacy and safety of the extended aorta CTA protocol in patients with AAs or ADs. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Analysis of Radiation Effects in Digital Subtraction Angiography of Intracranial Artery Stenosis.

PubMed

Guo, Chaoqun; Shi, Xiaolei; Ding, Xianhui; Zhou, Zhiming

2018-04-21

Intracranial artery stenosis (IAS) is the most common cause for acute cerebral accidents. Digital subtraction angiography (DSA) is the gold standard to detect IAS and usually brings excess radiation exposure to examinees and examiners. The artery pathology might influence the interventional procedure, causing prolonged radiation effects. However, no studies on the association between IAS pathology and operational parameters are available. A retrospective analysis was conducted on 93 patients with first-ever stroke/transient ischemic attack, who received DSA examination within 3 months from onset in this single center. Comparison of baseline characteristics was determined by 2-tailed Student's t-test or the chi-square test between subjects with and without IAS. A binary logistic regression analysis was performed to determine the association between IAS pathology and the items with a P value <0.05 in Student's t-test or chi-square test. There were 93 candidates (42 with IAS and 51 without IAS) in this study. The 2 groups shared no significance of the baseline characteristics (P > 0.05). We found a significantly higher total time, higher kerma area product, greater total dose, and greater DSA dose in the IAS group than in those without IAS (P < 0.05). A binary logistic regression analysis indicated the significant association between total time and IAS pathology (P < 0.05) but no significance in kerma area product, radiation dose, and DSA dose (P > 0.05). IAS pathology would indicate a prolonged total time of DSA procedure in clinical practice. However, the radiation effects would not change with pathologic changes. Copyright © 2018 Elsevier Inc. All rights reserved.

Noninvasive assessment of the intracranial pressure in non-traumatic intracranial hemorrhage.

PubMed

Vaiman, Michael; Sigal, Tal; Kimiagar, Itzhak; Bekerman, Inessa

2016-12-01

The article describes the modified technique of measuring the diameters of the optic nerve sheath (ONSD) for assessment of the intracranial pressure (ICP) in patients with intracerebral or subarachnoid hemorrhage (SAH). The CT scans of 443 patients were analyzed retrospectively. The ONSDs were measured at 3mm behind the globe and at the point where the ophthalmic artery crosses the optic nerve. The ONSD/eyeball transverse diameter (ETD) ratio was calculated. The correlation analysis was performed with the Glasgow Coma Scale score, Hemispheric Stroke Scale score, Glasgow Outcome Score, and invasive ICP readings. ONSD was enlarged in 95% of patients with intracerebral hemorrhage or SAH. Pathological ONSDs were 6.6±0.8mm (cut-off value >5.5mm; p<0.05). ONSD/ETD ratio was 0.29±0.05 against normative 0.19±0.02 (p<0.01) with no correlation with initial Glasgow Coma Scale score or Hemispheric Stroke Scale score. There was an inverse correlation between ONSD/ETD ratio and Glasgow Outcome Score (r=-0.7) and direct correlation with invasive ICP readings. This study provides further evidence that in patients with intracranial hemorrhage and SAH, the presence of ONSD greater than a threshold of 5.5mm is significantly predictive of invasively measured elevated ICP. The prediction of raised ICP can be further refined by measuring ONSD at the point where the optic nerve and the ophthalmic artery cross, and by determining the ratio between the ONSD and ETD. Copyright © 2016 Elsevier Ltd. All rights reserved.

DYNAMIC CEREBROVASCULAR AND INTRACRANIAL PRESSURE REACTIVITY ASSESMENT OF IMPAIRED CEREBROVASCULAR AUTOREGULATION IN INTRACRANIAL HYPERTENSION

PubMed Central

Bragin, Denis E.; Statom, Gloria; Nemoto, Edwin M.

2016-01-01

SUMMARY We previously suggested that the discrepancy between the critical cerebral perfusion pressures (CPP) of 30 mmHg, obtained by increasing intracranial pressure (ICP), and 60 mmHg, obtained by decreasing arterial pressure, was due to pathological microvascular shunting at high ICP [1] and that the determination of the critical CPP by the static cerebral blood flow (CBF) autoregulation curve is not valid with intracranial hypertension. Here we demonstrated that critical CPP, measured by induced dynamic ICP reactivity (iPRx) and cerebrovascular reactivity (CVRx), accurately identifies the critical CPP in the hypertensive rat brain which differs from that obtained by the static autoregulation curve. Step changes in CPP from 70 to 50 and 30 mmHg were made by increasing ICP using an artificial cerebrospinal fluid reservoir connected to the cisterna magna. At each CPP, a transient 10-mmHg rise in arterial pressure was induced by bolus i.v. dopamine. iPRx and iCVRx were calculated as ΔICP/ΔMAP and as ΔCBF/ΔMAP, respectively. The critical CPP at high ICP, obtained by iPRx and iCVRx, is 50 mmHg, where compromised capillary flow, transition of blood flow to non-nutritive microvascular shunts, tissue hypoxia and BBB leakage begin to occur, which is higher than the 30 mmHg determined by static autoregulation. PMID:27165917

Association between Champagne Bottle Neck Sign of Internal Carotid Artery and Ipsilateral Hemorrhagic Stroke in Patients with Moyamoya Disease.

PubMed

Wang, Jian; Chen, Gong; Yang, Yongbo; Zhang, Bing; Jia, Zhongzhi; Gu, Peiyuan; Wei, Dong; Ji, Jing; Hu, Weixing; Zhao, Xihai

2018-06-15

To assess the association between champagne bottle neck sign (CBNS) in carotid artery and intracranial hemorrhage in patients with moyamoya disease (MMD). From January 2016 to December 2017, a total of 76 consecutive patients with MMD without definite risk factors associated intracranial hemorrhage who underwent preoperative angiography were included in this retrospective study. CBNS was defined as luminal diameter of internal carotid artery (ICA)/common carotid artery (CCA) ≤ 0.5 on angiographic imaging. The right and left cerebral hemisphere in each patient was separately identified as hemorrhagic and none-hemorrhagic. The association between CBNS and intracranial hemorrhage was analyzed. Of 76 MMD patients, intracranial hemorrhage was found in 44 (28.9%) hemispheres of 152 and 6.8% (3/44) had multiple events. Compared carotid arteries without intracranial hemorrhage in the ipsilateral hemispheres, those with intracranial hemorrhage in the ipsilateral hemispheres had significantly smaller luminal diameter ratio of ICA/CCA (0.49 ± 0.11 vs. 0.55 ± 0.12, p < 0.01) and higher prevalence of CBNS (63.7% vs. 41.7%, p = 0.01). For hemispheres with intracranial hemorrhage, those with ipsilateral carotid artery CBNS had significantly higher prevalence of hemorrhage at posterior territories than those without (57.1% vs. 23.1%, p=0.05). Logistic regression revealed that CBNS was significantly associated with ipsilateral intracranial hemorrhage before (OR, 2.45; 95% CI, 1.19-5.05; p=0.02) and after (OR, 3.43; 95% CI, 1.50-7.87; p<0.01) adjusted for female, lenticulostriate anastomosis, and choroidal anastomosis. CBNS is significantly associated with intracranial hemorrhage at ipsilateral hemisphere in MMD patients, particularly for intracranial hemorrhage at posterior territories. Copyright © 2018. Published by Elsevier Inc.

Occipital Artery to Middle Cerebral Artery Bypass in Cases of Unavailable Superficial Temporal Artery.

PubMed

Hirano, Tsukasa; Mikami, Takeshi; Suzuki, Hime; Hirano, Toru; Kimura, Yusuke; Komatsu, Katusya; Akiyama, Yukinori; Wanibuchi, Masahiko; Mikuni, Nobuhiro

2018-04-01

In neurosurgery, extracranial-to-intracranial (EC-IC) bypass surgery is necessary for patients who have undergone surgery in which the superficial temporal artery (STA) was already used for a different bypass procedure or was damaged. Here we report our experience with EC-IC bypass using the occipital artery (OA) in patients in whom the STA was unavailable, and discuss the technical considerations and pitfalls. Five patients with ischemic-onset moyamoya disease and atherosclerotic disease were included. Two patterns of skin incisions were planned according to the OA pathway and recipient artery location. In one of these methods, a skin incision is made above the OA, and a craniotomy is performed under this incision after OA dissection. In the other method, a skin incision is made above the OA to enable its dissection, and a craniotomy is performed via a separate skin incision. No major perioperative complications developed in any of the 5 cases, and bypass patency was confirmed in all patients. There was a significant difference between the preoperative and postoperative asymmetry ratios of the mean transit time values. Our findings suggest that OA-to-middle cerebral artery (MCA) bypass is a simple and effective technique in patients in whom the STA was already used or was damaged by previous intracranial revascularization or craniotomy. This procedure could be an alternative to STA-MCA bypass in patients without an available STA. Copyright © 2018 Elsevier Inc. All rights reserved.

Decreased muscle mass in Korean subjects with intracranial arterial stenosis: The Kangbuk Samsung Health Study.

PubMed

Jung, Ho-Jung; Jung, Hwanseok; Lee, Taeyoung; Kim, Jongho; Park, Jongsin; Kim, Hacsoo; Cho, Junghwan; Lee, Won-Young; Park, Sung-Woo; Rhee, Eun-Jung; Oh, Hyung-Geun

2017-01-01

Intracranial arterial stenosis (ICAS) is a common cause of ischemic stroke in Asians. Decreased muscle mass is one of the major causes of chronic disease in adults. The purpose of this study was to analyze the relationship between muscle mass and ICAS in Korean adults. For this study, we selected a total of 10,530 participants (mean age, 43.3 years; 8558 men) in a health screening program, for whom transcranial Doppler (TCD) ultrasound was used to detect >50% ICAS based on criteria modified from the stroke outcomes and neuroimaging of intracranial atherosclerosis trial. Body composition was evaluated by bioelectrical impedance analysis (BIA). Skeletal muscle index (SMI) was calculated with muscle mass/weight (kg) * 100. Among the total patient population, 322 (3.1%) subjects had ICAS. Subjects with ICAS were older, and had higher mean values for fasting glucose, body mass index and blood pressure compared with those without ICAS. Subjects with ICAS had significantly lower muscle mass, SMI and higher percent body fat compared with those without ICAS. In logistic regression analysis, the subjects in the highest tertile of muscle mass had the lowest odds ratio for ICAS with the lowest tertile group of muscle mass as the reference group even after adjusting for age, systolic blood pressure, fasting blood glucose, sex, smoking and exercise (OR 0.650, 95% CI 0.442-0.955). Subjects with ICAS had significantly decreased muscle mass compared with those without ICAS in Korean adults. The risk for ICAS was lower in subjects with higher muscle mass. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Combination Superficial Temporal Artery-Middle Cerebral Artery Bypass and M2-M2 Reanastomosis With Trapping of a Stented Distal Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

PubMed

Burkhardt, Jan-Karl; Yousef, Sonia; Tabani, Halima; Benet, Arnau; Rubio, Roberto Rodriguez; Lawton, Michael T

2018-05-12

Distal middle cerebral artery (MCA) aneurysms often have non-saccular morphology and cannot be clipped, requiring revascularization and trapping instead. Combination bypasses are needed when 2 arteries exit the aneurysm, and extracranial-intracranial and intracranial-intracranial bypasses can be used. This video demonstrates a combination bypass used to treat a previously stented distal MCA aneurysm with both a superficial temporal artery (STA)-to-MCA bypass and an M2-to-M2 reanastomosis. This 56-yr-old man presented with distal left-sided MCA aneurysm 2 years earlier and attempted stent-assisted coiling was aborted after the aneurysm was perforated with stenting alone. Follow-up angiography demonstrated progressive aneurysm enlargement, and he was referred for surgery. The patient consented for the procedure and a pterional craniotomy extended posteriorly exposed the distal Sylvian fissure and efferent M4-cortical arteries. After splitting the Sylvian fissure, the "flash fluorescence" technique with indocyanine green (ICG) videoangiography identified an M4 recipient artery from the deeper of 2 exiting branches for STA-MCA bypass.1 The aneurysm was then trapped, and inflow and the more superficial outflow arteries were anastomosed end to end (M2-M2 in-situ bypass). A platelet plug that developed at the reanastomosis site was broken apart with mechanical manipulation, and ICG videoangiography demonstrated patency of both bypasses. The patient recovered without any neurological deficits, and postoperative computed tomography angiography confirmed bypass patency. Combination bypasses are needed when unclippable bifurcation aneurysms require revascularization. Careful intraoperative evaluation of patency of the bypass is imperative and helps identifying and addressing any potential early bypass occlusion.

Progression of symptomatic intracranial large artery atherosclerosis is associated with a proinflammatory state and impaired fibrinolysis.

PubMed

Arenillas, Juan F; Alvarez-Sabín, José; Molina, Carlos A; Chacón, Pilar; Fernández-Cadenas, Israel; Ribó, Marc; Delgado, Pilar; Rubiera, Marta; Penalba, Anna; Rovira, Alex; Montaner, Joan

2008-05-01

The molecular pathways involved in the progression of intracranial large artery atherosclerosis (ILA) are largely unknown. Our objective was to prospectively study the relationship between circulating levels of inflammatory markers and fibrinolysis inhibitors, and the risk of progression of symptomatic ILA. Seventy-five consecutive patients with first-ever symptomatic intracranial atherostenosis were studied. Blood levels of C-reactive protein (CRP), E-selectin, monocyte chemoattractant protein-1, intercellular adhesion molecule-1, matrix metalloproteinases 1, 2, 3, 8, 9, 10, and 13, plasminogen activator inhibitor-1 (PAI-1), and lipoprotein(a) were measured 3 months after the qualifying stroke or transient ischemic attack. Thereafter, patients underwent long-term transcranial Doppler follow-up to detect progression of ILA. During a median follow-up time of 23 months, 25 (33%) patients showed ILA progression. Multivariable adjusted Cox regression models and Kaplan-Meier curves showed that high baseline level of CRP, E-selectin, intercellular adhesion molecule-1, matrix metalloproteinase 9, PAI-1, and lipoprotein(a) predicted ILA progression independently of vascular risk factors. Of them, only CRP (CRP>5.5 mg/L; HR, 5.4 [2.3 to 12.7]; P=0.0001) and PAI-1 (PAI-1>23.1 ng/mL; HR, 2.4 [1.0 to 5.8]; P=0.05) predicted ILA progression also independently of the other studied molecules. Progression of symptomatic ILA is associated with a proinflammatory state, as reflected by high levels of inflammatory markers, and with defective fibrinolysis, as indicated by raised concentrations of endogenous fibrinolysis inhibitors.

Gadolinium Enhancement in Intracranial Atherosclerotic Plaque and Ischemic Stroke: A Systematic Review and Meta-Analysis.

PubMed

Gupta, Ajay; Baradaran, Hediyeh; Al-Dasuqi, Khalid; Knight-Greenfield, Ashley; Giambrone, Ashley E; Delgado, Diana; Wright, Drew; Teng, Zhongzhao; Min, James K; Navi, Babak B; Iadecola, Costantino; Kamel, Hooman

2016-08-15

Gadolinium enhancement on high-resolution magnetic resonance imaging (MRI) has been proposed as a marker of inflammation and instability in intracranial atherosclerotic plaque. We performed a systematic review and meta-analysis to summarize the association between intracranial atherosclerotic plaque enhancement and acute ischemic stroke. We searched the medical literature to identify studies of patients undergoing intracranial vessel wall MRI for evaluation of intracranial atherosclerotic plaque. We recorded study data and assessed study quality, with disagreements in data extraction resolved by a third reader. A random-effects odds ratio was used to assess whether, in any given patient, cerebral infarction was more likely in the vascular territory supplied by an artery with MRI-detected plaque enhancement as compared to territory supplied by an artery without enhancement. We calculated between-study heterogeneity using the Cochrane Q test and publication bias using the Begg-Mazumdar test. Eight articles published between 2011 and 2015 met inclusion criteria. These studies provided information about plaque enhancement characteristics from 295 arteries in 330 patients. We found a significant positive relationship between MRI enhancement and cerebral infarction in the same vascular territory, with a random effects odds ratio of 10.8 (95% CI 4.1-28.1, P<0.001). No significant heterogeneity (Q=11.08, P=0.14) or publication bias (P=0.80) was present. Intracranial plaque enhancement on high-resolution vessel wall MRI is strongly associated with ischemic stroke. Evaluation for plaque enhancement on MRI may be a useful test to improve diagnostic yield in patients with ischemic strokes of undetermined etiology. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Cerebral blood flow changes in response to elevated intracranial pressure in rabbits and bluefish: a comparative study.

PubMed

Beiner, J M; Olgivy, C S; DuBois, A B

1997-03-01

In mammals, the cerebrovascular response to increases in intracranial pressure may take the form of the Cushing response, which includes increased mean systemic arterial pressure, bradycardia and diminished respirations. The mechanism, effect and value of these responses are debated. Using laser-Doppler flowmetry to measure cerebral blood flow, we analyzed the cardiovascular responses to intracranial pressure raised by epidural infusion of mock cerebrospinal fluid in the bluefish and in the rabbit, and compare the results. A decline in cerebral blood flow preceding a rise in mean systemic arterial pressure was observed in both species. Unlike bluefish, rabbits exhibit a threshold of intracranial pressure below which cerebral blood flow was maintained and no cardiovascular changes were observed. The difference in response between the two species was due to the presence of an active autoregulatory system in the cerebral tissue of rabbits and its absence in bluefish. For both species studied, the stimulus for the Cushing response seems to be a decrement in cerebral blood flow. The resulting increase in the mean systemic arterial pressure restores cerebral blood flow to levels approaching controls.

[Actual review of diagnostics and endovascular therapy of intracranial arterial stenoses].

PubMed

Gizewski, E R; Weber, R; Forsting, M

2011-02-01

Approximately 6 - 50% of all ischemic strokes are caused by intracranial arterial stenosis (IAS). Despite medical prevention, patients with symptomatic IAS have a high annual risk for recurrent ischemic stroke of about 12%, and up to 19% in the case of high-grade IAS (≥ 70%). Digital subtraction angiography remains the gold standard for the diagnosis and grading of IAS. However, noninvasive imaging techniques including CT angiography, MR angiography, or transcranial Doppler and duplex ultrasound examinations are used in the clinical routine to provide additional information about the brain structure and hemodynamic. However, for technical reasons, the grading of stenoses is sometimes difficult and inaccurate. To date, aspirin is recommended as the treatment of choice in the prevention of recurrent ischemic stroke in patients with IAS. IAS patients who suffer a recurrent ischemic stroke or transient ischemic attack while taking aspirin can be treated with endovascular stenting or angioplasty in specialized centers. The periprocedural complication rate of these endovascular techniques is about 2 - 7% at experienced neuro-interventional centers. The rate of re-stenosis is reported between 10 and 40% depending on patient age and stenosis location. Further randomized studies comparing medical secondary prevention and endovascular therapy are currently being performed. With regard to the improvement of endovascular methods and lower complication rates, the indication for endovascular therapy in IAS could be broadened especially for stenosis in the posterior circulation. © Georg Thieme Verlag KG Stuttgart · New York.

Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial.

PubMed

Derdeyn, Colin P; Chimowitz, Marc I; Lynn, Michael J; Fiorella, David; Turan, Tanya N; Janis, L Scott; Montgomery, Jean; Nizam, Azhar; Lane, Bethany F; Lutsep, Helmi L; Barnwell, Stanley L; Waters, Michael F; Hoh, Brian L; Hourihane, J Maurice; Levy, Elad I; Alexandrov, Andrei V; Harrigan, Mark R; Chiu, David; Klucznik, Richard P; Clark, Joni M; McDougall, Cameron G; Johnson, Mark D; Pride, G Lee; Lynch, John R; Zaidat, Osama O; Rumboldt, Zoran; Cloft, Harry J

2014-01-25

Early results of the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial showed that, by 30 days, 33 (14·7%) of 224 patients in the stenting group and 13 (5·8%) of 227 patients in the medical group had died or had a stroke (percentages are product limit estimates), but provided insufficient data to establish whether stenting offered any longer-term benefit. Here we report the long-term outcome of patients in this trial. We randomly assigned (1:1, stratified by centre with randomly permuted block sizes) 451 patients with recent transient ischaemic attack or stroke related to 70-99% stenosis of a major intracranial artery to aggressive medical management (antiplatelet therapy, intensive management of vascular risk factors, and a lifestyle-modification programme) or aggressive medical management plus stenting with the Wingspan stent. The primary endpoint was any of the following: stroke or death within 30 days after enrolment, ischaemic stroke in the territory of the qualifying artery beyond 30 days of enrolment, or stroke or death within 30 days after a revascularisation procedure of the qualifying lesion during follow-up. Primary endpoint analysis of between-group differences with log-rank test was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT 00576693. During a median follow-up of 32·4 months, 34 (15%) of 227 patients in the medical group and 52 (23%) of 224 patients in the stenting group had a primary endpoint event. The cumulative probability of the primary endpoints was smaller in the medical group versus the percutaneous transluminal angioplasty and stenting (PTAS) group (p=0·0252). Beyond 30 days, 21 (10%) of 210 patients in the medical group and 19 (10%) of 191 patients in the stenting group had a primary endpoint. The absolute differences in the primary endpoint rates between the two groups were 7·1% at year 1 (95% CI 0·2 to 13·8%; p=0·0428), 6·5% at year 2

Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial

PubMed Central

Derdeyn, Colin P; Chimowitz, Marc I; Lynn, Michael J; Fiorella, David; Turan, Tanya N; Janis, L Scott; Montgomery, Jean; Nizam, Azhar; Lane, Bethany F; Lutsep, Helmi L; Barnwell, Stanley L; Waters, Michael F; Hoh, Brian L; Hourihane, J Maurice; Levy, Elad I; Alexandrov, Andrei V; Harrigan, Mark R; Chiu, David; Klucznik, Richard P; Clark, Joni M; McDougall, Cameron G; Johnson, Mark D; Pride, G Lee; Lynch, John R; Zaidat, Osama O; Rumboldt, Zoran; Cloft, Harry J

2014-01-01

Summary Background Early results of the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial showed that, by 30 days, 33 (14·7%) of 224 patients in the stenting group and 13 (5·8%) of 227 patients in the medical group had died or had a stroke (percentages are product limit estimates), but provided insufficient data to establish whether stenting offered any longer-term benefit. Here we report the long-term outcome of patients in this trial. Methods We randomly assigned (1:1, stratified by centre with randomly permuted block sizes) 451 patients with recent transient ischaemic attack or stroke related to 70–99% stenosis of a major intracranial artery to aggressive medical management (antiplatelet therapy, intensive management of vascular risk factors, and a lifestyle-modification programme) or aggressive medical management plus stenting with the Wingspan stent. The primary endpoint was any of the following: stroke or death within 30 days after enrolment, ischaemic stroke in the territory of the qualifying artery beyond 30 days of enrolment, or stroke or death within 30 days after a revascularisation procedure of the qualifying lesion during follow-up. Primary endpoint analysis of between-group differences with log-rank test was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT 00576693. Findings During a median follow-up of 32·4 months, 34 (15%) of 227 patients in the medical group and 52 (23%) of 224 patients in the stenting group had a primary endpoint event. The cumulative probability of the primary endpoints was smaller in the medical group versus the percutaneous transluminal angioplasty and stenting (PTAS) group (p=0·0252). Beyond 30 days, 21 (10%) of 210 patients in the medical group and 19 (10%) of 191 patients in the stenting group had a primary endpoint. The absolute differences in the primary endpoint rates between the two groups were 7·1% at year 1 (95% CI 0·2 to

Screen for intracranial dural arteriovenous fistulae with carotid duplex sonography.

PubMed

Tsai, L-K; Yeh, S-J; Chen, Y-C; Liu, H-M; Jeng, J-S

2009-11-01

Early diagnosis and management of intracranial dural arteriovenous fistulae (DAVF) may prevent the occurrence of stroke. This study aimed to identify the best carotid duplex sonography (CDS) parameters for screening DAVF. 63 DAVF patients and 170 non-DAVF patients received both CDS and conventional angiography. The use of seven CDS haemodynamic parameter sets related to the resistance index (RI) of the external carotid artery (ECA) for the diagnosis of DAVF was validated and the applicability of the best CDS parameter set in 20 400 patients was tested. The CDS parameter set (ECA RI (cut-off point = 0.7) and internal carotid artery (ICA) to ECA RI ratio (cut-off point = 0.9)) had the highest specificity (99%) for diagnosis of DAVF with moderate sensitivity (51%). Location of the DAVF was a significant determinant of sensitivity of detection, which was 70% for non-cavernous DAVF and 0% for cavernous sinus DAVF (p<0.001). The above parameter set detected abnormality in 92 of 20 400 patients. These abnormalities included DAVF (n = 25), carotid stenosis (n = 32), vertebral artery stenosis (n = 7), intracranial arterial stenosis (n = 6), head and neck tumour (n = 3) and unknown aetiology (n = 19). Combined CDS parameters of ECA RI and ICA to ECA RI ratio can be used as a screening tool for the diagnosis of DAVF.

Clipping in Awake Surgery as End-Stage in a Complex Internal Carotid Artery Aneurysm After Failure of Multimodal Endovascular and Extracranial-Intracranial Bypass Treatment.

PubMed

Cannizzaro, Delia; Peschillo, Simone; Mancarella, Cristina; La Pira, Biagia; Rastelli, Emanuela; Passacantilli, Emiliano; Santoro, Antonio

2017-06-01

Intracranial carotid artery aneurysm can be treated via microsurgical or endovascular techniques. The optimal planning is the result of the careful patient selection through clinical, anatomic, and angiographic analysis. We present a case of ruptured internal carotid artery (ICA) aneurysm that became a complex aneurysm after failure of multi-endovascular and surgery treatment. We describe complete trapping in awake craniotomy after failure of coiling, stenting, and bypassing. ICA aneurysms could become complex aneurysms following multi-treatment failure. Endovascular approaches to treat ICA aneurysms include coiling, stenting, flow diverter stenting, and stenting-assisted coiling technique. The role of surgery remains relevant. To avoid severe neurologic deficits, recurrence, and the need of retreatment, a multidisciplinary discussion with experienced endovascular and vascular neurosurgeons is mandatory in such complex cases. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Association of Inter-arm Blood Pressure Difference with Asymptomatic Intracranial and Extracranial Arterial Stenosis in Hypertension Patients.

PubMed

Wang, Yan; Zhang, Jin; Qian, Yuesheng; Tang, Xiaofeng; Ling, Huawei; Chen, Kemin; Li, Yan; Gao, Pingjin; Zhu, Dingliang

2016-07-14

Inter-arm blood pressure (BP) difference has been associated with ischemic stroke. Local atherosclerosis of stroke differ among vulnerable individuals, whereas intracranial arterial stenosis (ICAS) is more frequently affected Asians, and extracranial arterial stenosis (ECAS) is more prevalent among whites. We hereby sought to explore the association of inter-arm BP difference with ICAS and ECAS in stroke-free hypertensive patients in Chinese population. All the 885 subjects were evaluated of ICAS and ECAS through computerized tomographic angiography. Both arm BP was measured simultaneously by Vascular Profiler-1000 device. In the continuous study, ICAS was significantly associated with age, male, average brachial SBP, diabetes, anti-hypertensive treatment and inter-arm DBP difference. ECAS was associated with age, inter-arm SBP and LDL. In the categorical study, subjects with the top quartile of inter-arm DBP difference (≥4 mmHg) showed significantly higher risk of ICAS (OR = 2.109; 95% CI, 1.24-3.587). And the participants with the top quartile of inter-arm SBP difference (≥6 mmHg) showed significantly higher risk of ECAS (OR = 2.288; 95% CI, 1.309-3.998). In conclusion, we reported a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS. Inter-arm DBP difference might be the early symbol of ICAS in Chinese population, which need further verification in long-term cohort study.

[3-D angiography in diagnosis and treatment of intracranial aneurysm].

PubMed

Wang, D; Ling, F; Liu, S

2001-09-01

To summarize the results of initial application of three-dimensional angiography (3D-Angio) in diagnosis and treatment of intracranial aneurysms. From August 1999 to January 2001, standard digital subtraction angiography (two-dimensional angiography, 2D-Angio) and 3D-Angio(obtained by reconstruction of rotational angiography) were performed in 65 patients with confirmed or suspected aneurysms. Sixty-six aneurysms were found in 60 patients and nothing was found in 5. Of 66 the aneurysms (60 cases), 46 (43 cases) were treated by intrasaccule embolizotion with coils, 3 (3 cases) by occluding the parent artery with detachable balloon, 10 (10 cases) by surgery, and 1 (1 case) by combination of extracranial-intracranial bypass and balloon occlusion of parent artery. Six (3 cases) were not treated. Two aneurysms that could not be detected by 2D-Angio were diagnosed by 3D-Angio. Three aneurysms that were difficult or dangerous to embolize by 2D-Angio were embolized successfully with the help of 3D-Angio. Three aneurysms seemed to be embolized on 2D-Angio were proved impossible to be embolized on 3D-Angio. Of the 46 aneurysms embolized intrasaccularly, 38(82.6%) were completely embolized on 2D-Angio. In the 38, 8 had residual aneurysm on 3D-Angio. More accurate diagnosis and secure treatment of intracranial aneurysm can be reached by 3D-Angio.

Dual-Image Videoangiography During Intracranial Microvascular Surgery.

PubMed

Feletti, Alberto; Wang, Xiangdong; Tanaka, Riki; Yamada, Yasuhiro; Suyama, Daisuke; Kawase, Tsukasa; Sano, Hirotoshi; Kato, Yoko

2017-03-01

Indocyanine green videoangiography (ICG-VA) is a valuable tool to assess vessel and aneurysm patency during neurovascular surgical procedures. However, ICG-VA highlights vascular structures, which appear white over a black background. Anatomic relationships are sometimes difficult to understand at first glance. Dual-image videoangiography (DIVA) enables simultaneous visualization of light and near-infrared fluorescence images of ICG-VA. The DIVA system was mounted on an OPMI Pentero Flow 800 intraoperative microscope. DIVA was used during microsurgical procedures on 5 patients who were operated for aneurysm clipping and superficial temporal artery-middle cerebral artery bypass. DIVA provides real-time simultaneous visualization of aneurysm and vessels and surrounding structures including brain, nerves, and surgical clips. Although visual contrast between vessels and background is higher with standard black-and-white imaging, DIVA makes it easier to understand anatomic relationships between intracranial structures. DIVA also provides better vision of the depth of field. DIVA has the potential to become a widely used intraoperative tool to check patency of intracranial vessels. It should be considered as an adjunct to standard ICG-VA for better understanding of vascular anatomy in relation to surrounding structures and can have an impact on decision making during surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

[POSITIVE END-EXPIRATORY PRESSURE (PEEP) INFLUENCES ON INTRACRANIAL PRESSURE, SYSTEMIC HEMODYNAMICS AND PULMONARY GAS EXCHANGE IN PATIENTS WITH INTRACRANIAl HEMORRHAGE IN CRITICAL STATE].

PubMed

Solodov, A A; Petrikov, S S; Krylov, V V

2016-01-01

Positive end-expiratory pressure is one of the main parameters of respiratory support influencing the gas exchange. However, despite the number ofpositive effects, PEEP can compromise venous outflow from the cranial cavity, increased intracranial pressure, decreased venous return and cardiac output and, consequently, reduced blood pressure and cerebral perfusion. The article presents the results of a survey of 39 patients with intracranial hemorrhage in critical state, undergoing respiratory support with different levels of positive end-expiratory pressure. Increasing of PEEP to 15 cm H2O had no adverse effect on mean arterial pressure, heart rate and cerebral perfusion pressure and led only to an clinical insignificant increase (maximum on 2.4 +/- 5.1 mmHg) in intracranial pressure. The greatest hemodynamic changes were observed with increasing PEEP up to 20 cm H2O in patients with preserved compliance ofthe respiratory system. The instability of cerebral perfusion and intracranial pressure associated with a decrease in cardiac output and preload and the exhaustion of compensatory mechanism of peripheral vascular resistance. High levels of PEEP despite the trend towards Cstat reduction will not lead to an increase in the content of extravascular lung water Thus a gradual increase of PEEP to 15 cm H2O can be safe and effective method of improving pulmonary gas exchange in patients with intracranial hemorrhage in critical state.

[Classification of cerebrovascular processes using ultrasound methods].

PubMed

Klein, K

1984-01-01

By means of ultrasound A-mode echography and Doppler-Kranzbühler sonography new fundamentals of non-invasive qualitative and quantitative classification of cerebrovascular processes could be developed: Apart from usual screening of stenoses and pulse curve analyses, measurements of diameters and wall movements in the extracranial and intracranial carotid artery and in the vertebral artery as well as determinations of the systolic and diastolic flow velocities in the extracranial arteries are outstanding features. By recording and evaluating these parameters and data patterns, coupled with clinical findings, differential conclusions on reactions of the cerebral hemodynamics in macrocirculatory and microcirculatory regions were realized in geriatric patients under the following pathophysiological and therapeutically induced conditions: Generally and regionally accentuated arteriosclerotic lesions of the brain (predominant vertebrobasilar insufficiency), decrease of flow velocities according to the diameter, aggravation by distress; principal possibility of pharmacological influence if myogenic autoregulation function is rehabilitable: It is demonstrated by the example of a long-term therapy with a combination of Raubasine, Dihydroergocristine and DHE (Defluina forte).

Clinical research of persimmon leaf extract and ginkgo biloba extract in the treatment of vertebrobasilar insufficiency.

PubMed

Guo, S G; Guan, S H; Wang, G M; Liu, G Y; Sun, H; Wang, B J; Xu, F

2015-01-01

This paper aims to compare the curative effects of persimmon leaf extract and ginkgo biloba extract in the treatment of headache and dizziness caused by vertebrobasilar insufficiency. Sixty patients were observed, who underwent therapy with persimmon leaf extract and ginkgo biloba extract based on the treatment of nimodipine and aspirin. After 30 days, 30 patients treated with persimmon leaf extract and 30 patients with ginkgo biloba extract were examined for changes in hemodynamic indexes and symptoms, such as headache and dizziness. The results showed statistically significant differences of 88.3% for the persimmon leaf extract and 73.1% for the ginkgo biloba extract, P < 0.05. Compared to the group of ginkgo biloba extract, the group of persimmon leaf extract had more apparent improvement in the whole blood viscosity, plasma viscosity, fibrinogen, hematokrit, and platelet adhesion rate, and the difference was statistically significant (P < 0.05 or P < 0.01). Based on these analyses, it can be concluded that persimmon leaf extract is better than ginkgo biloba extract in many aspects, such as cerebral circulation improvement, cerebral vascular expansion, hypercoagulable state lowering and vertebrobasilar insufficiency-induced headache and dizziness relief.

Calcification at orifices of aortic arch branches is a reliable and significant marker of stenosis at carotid bifurcation and intracranial arteries.

PubMed

Yamada, Shigeki; Hashimoto, Kenji; Ogata, Hideki; Watanabe, Yoshihiko; Oshima, Marie; Miyake, Hidenori

2014-02-01

Simple rating scale for calcification in the cervical arteries and the aortic arch on multi-detector computed tomography angiography (MDCTA) was evaluated its reliability and validity. Additionally, we investigated where is the most representative location for evaluating the calcification risk of carotid bifurcation stenosis and atherosclerotic infarction in the overall cervical arteries covering from the aortic arch to the carotid bifurcation. The aortic arch and cervical arteries among 518 patients (292 men, 226 women) were evaluated the extent of calcification using a 4-point grading scale for MDCTA. Reliability, validity and the concomitant risk with vascular stenosis and atherosclerotic infarction were assessed. Calcification was most frequently observed in the aortic arch itself, the orifices from the aortic arch, and the carotid bifurcation. Compared with the bilateral carotid bifurcations, the aortic arch itself had a stronger inter-observer agreement for the calcification score (Fleiss' kappa coefficients; 0.77), but weaker associations with stenosis and atherosclerotic infarction. Calcification at the orifices of the aortic arch branches had a stronger inter-observer agreement (0.74) and enough associations with carotid bifurcation stenosis and intracranial stenosis. In addition, the extensive calcification at the orifices from the aortic arch was significantly associated with atherosclerotic infarction, similar to the calcification at the bilateral carotid bifurcations. The orifices of the aortic arch branches were the novel representative location of the aortic arch and overall cervical arteries for evaluating the calcification extent. Thus, calcification at the aortic arch should be evaluated with focus on the orifices of 3 main branches. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Distal Embolization After Stenting of the Vertebral Artery: Diffusion-Weighted Magnetic Resonance Imaging Findings

DOE Office of Scientific and Technical Information (OSTI.GOV)

Canyigit, Murat; Arat, Anil; Cil, Barbaros E.

2007-04-15

Purpose. We retrospectively evaluated our experience with stenting of the vertebral artery in an effort to determine the risk of distal embolization associated with the procedure. Methods. Between June 2000 and May 2005, 35 patients with 38 stenting procedures for atherosclerotic disease of the vertebral origin in our institution were identified. The average age of the patients was 60.3 years (range 32-76 years). Sixteen of these patients (with 18 stents) had MR imaging of the brain with diffusion-weighted imaging and an apparent diffusion coefficient map within 2 days before and after procedure. Results. On seven of the 16 postprocedural diffusion-weightedmore » MR images, a total of 57 new hyperintensities were visible. All these lesions were focal in nature. One patient demonstrated a new diffusion-weighted imaging abnormality in the anterior circulation without MR evidence of posterior circulation ischemia. Six of 16 patients had a total of 25 new lesions in the vertebrobasilar circulation in postprocedural diffusion-weighted MR images. One patient in this group was excluded from the final analysis because the procedure was complicated by basilar rupture during tandem stent deployment in the basilar artery. Hence, new diffusion-weighted imaging abnormalities were noted in the vertebrobasilar territory in 5 of 15 patients after 17 stenting procedures, giving a 29% rate of diffusion-weighted imaging abnormalities per procedure. No patient with bilateral stenting had new diffusion-weighted imaging abnormalities. Conclusion. Stenting of stenoses of the vertebral artery origin may be associated with a significant risk of asymptomatic distal embolization. Angiography, placement of the guiding catheter, inflation of the stent balloon, and crossing the lesion with guidewires or balloon catheters may potentially cause distal embolization. Further studies to evaluate measures to increase the safety of vertebral artery stenting, such as the use of distal protection

The Clinical Importance of Perforator Preservation in Intracranial Aneurysm Surgery: An Overview with a Review of the Literature.

PubMed

Joo, Sung-Pil; Kim, Tae-Sun

2017-01-01

Clipping for intracranial aneurysms is done to achieve complete occlusion of the aneurysm without a remnant sac. Despite modern advancements of neurosurgical techniques, morbidity related to the clipping of intracranial aneurysms still exists. Clip occlusion of a parent artery or small hidden perforators commonly leads to permanent neurological deficits, and is a serious and unwanted complication. Thus, preserving blood flow in the branches and perforators of a parent artery is very important for successful surgery without postoperative morbidity and mortality. The aim of this review article is to discuss the consequences of perforator injury and how to avoid this phenomenon in aneurysm surgeries using intraoperative monitoring devices.

Management of Carotid Artery Trauma

PubMed Central

Lee, Thomas S.; Ducic, Yadranko; Gordin, Eli; Stroman, David

2014-01-01

With increased awareness and liberal screening of trauma patients with identified risk factors, recent case series demonstrate improved early diagnosis of carotid artery trauma before they become problematio. There remains a need for unified screening criteria for both intracranial and extracranial carotid trauma. In the absence of contraindications, antithrombotic agents should be considered in blunt carotid artery injuries, as there is a significant risk of progression of vessel injury with observation alone. Despite CTA being used as a common screening modality, it appears to lack sufficient sensitivity. DSA remains to be the gold standard in screening. Endovascular techniques are becoming more widely accepted as the primary surgical modality in the treatment of blunt extracranial carotid injuries and penetrating/blunt intracranial carotid lessions. Nonetheless, open surgical approaches are still needed for the treatment of penetrating extracranial carotid injuries and in patients with unfavorable lesions for endovascular intervention. PMID:25136406

Association of Inter-arm Blood Pressure Difference with Asymptomatic Intracranial and Extracranial Arterial Stenosis in Hypertension Patients

PubMed Central

Wang, Yan; Zhang, Jin; Qian, Yuesheng; Tang, Xiaofeng; Ling, Huawei; Chen, Kemin; Li, Yan; Gao, Pingjin; Zhu, Dingliang

2016-01-01

Inter-arm blood pressure (BP) difference has been associated with ischemic stroke. Local atherosclerosis of stroke differ among vulnerable individuals, whereas intracranial arterial stenosis (ICAS) is more frequently affected Asians, and extracranial arterial stenosis (ECAS) is more prevalent among whites. We hereby sought to explore the association of inter-arm BP difference with ICAS and ECAS in stroke-free hypertensive patients in Chinese population. All the 885 subjects were evaluated of ICAS and ECAS through computerized tomographic angiography. Both arm BP was measured simultaneously by Vascular Profiler-1000 device. In the continuous study, ICAS was significantly associated with age, male, average brachial SBP, diabetes, anti-hypertensive treatment and inter-arm DBP difference. ECAS was associated with age, inter-arm SBP and LDL. In the categorical study, subjects with the top quartile of inter-arm DBP difference (≥4 mmHg) showed significantly higher risk of ICAS (OR = 2.109; 95% CI, 1.24–3.587). And the participants with the top quartile of inter-arm SBP difference (≥6 mmHg) showed significantly higher risk of ECAS (OR = 2.288; 95% CI, 1.309–3.998). In conclusion, we reported a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS. Inter-arm DBP difference might be the early symbol of ICAS in Chinese population, which need further verification in long-term cohort study. PMID:27412818

Endovascular revascularization results in IMS III: intracranial ICA and M1 occlusions.

PubMed

Tomsick, Thomas A; Yeatts, Sharon D; Liebeskind, David S; Carrozzella, Janice; Foster, Lydia; Goyal, Mayank; von Kummer, Ruediger; Hill, Michael D; Demchuk, Andrew M; Jovin, Tudor; Yan, Bernard; Zaidat, Osama O; Schonewille, Wouter; Engelter, Stefan; Martin, Renee; Khatri, Pooja; Spilker, Judith; Palesch, Yuko Y; Broderick, Joseph P

2015-11-01

Interventional Management of Stroke III did not show that combining IV recombinant tissue plasminogen activator (rt-PA) with endovascular therapies (EVTs) is better than IV rt-PA alone. To report efficacy and safety results for EVT of intracranial internal carotid artery (ICA) and middle cerebral artery trunk (M1) occlusion. Five revascularization methods for persistent occlusions after IV rt-PA treatment were evaluated for prespecified primary and secondary endpoints, after accounting for differences in key baselines variables using propensity scores. Revascularization was scored using the arterial occlusive lesion (AOL) and the modified Thrombolysis in Cerebral Ischemia (mTICI) scores. EVT of 200 subjects with intracranial ICA or M1 occlusion resulted in 81.5% AOL 2-3 recanalization, in addition to 76% mTICI 2-3 and 42.5% mTICI 2b-3 reperfusion. Adverse events included symptomatic intracranial hemorrhage (SICH) (8.0%), vessel perforations (1.5%), and new emboli (14.9%). EVT techniques used were standard microcatheter n=51; EKOS n=14; Merci n=77; Penumbra n=39; Solitaire n=4; multiple n=15. Good clinical outcome was associated with both TICI 2-3 and TICI 2b-3 reperfusion. Neither modified Rankin scale (mRS) 0-2 (28.5%), nor 90-day mortality (28.5%), nor asymptomatic ICH (36.0%) differed among revascularization methods after propensity score adjustment for subjects with intracranial ICA or M1 occlusion. Good clinical outcome was associated with good reperfusion for ICA and M1 occlusion. No significant differences in efficacy or safety among revascularization methods were demonstrated after adjustment. Lack of high-quality reperfusion, adverse events, and prolonged time to treatment contributed to lower-than-expected mRS 0-2 outcomes and study futility compared with IV rt-PA. NCT00359424. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

The impact of laser irradiation on global stability in patients with vertebrobasilar insufficiency: A clinical report

PubMed Central

Lukowicz, Malgorzata; Zalewski, Pawel; Bulatowicz, Irena; Buszko, Katarzyna; Klawe, Jacek J.

2011-01-01

Summary Background The purpose of our experiment was to determine whether laser stimulation can improve microcirculation in the posterior regions of the brain in patients with vertebrobasilar insufficiency (VBI). Material/Methods We studied 25 patients (20 female, 5 male, mean age 64) diagnosed with chronic VBI. All were evaluated using the De Klyn test, followed by qualitative assessment of stability using a Berg Balance Scale and evaluation of global stability using an electronic balance platform. A CTL-1100 low power laser was used with standard parameters. We established a protocol for laser irradiation at 5 points along the vertebral artery in the cervical region bilaterally. Irradiation was performed 10 times over two weeks. Results Significant improvement occurred after therapy in headache (p=0.0005), vertigo (p<0.0000), and tinnitus (p=0.0387). No significant differences were observed in nausea or nystagmus caused by head rotation. The Berg Balance Scale results showed significant differences in almost all features. There was a tendency towards improved stability in all parameters, and statistically significant differences in the total surface of support and the spread surface of support for the left foot. Conclusions Laser stimulation as applied in this study can be useful in the treatment of patients with VBI. The main reason for improvement in global stability, balance, and other VBI symptoms is better blood perfusion. PMID:21873949

Intraoperative sonographic assessment of graft patency during extracranial-intracranial bypass.

PubMed

Badie, B; Lee, F T; Pozniak, M A; Strother, C M

2000-09-01

Extracranial-intracranial (EC-IC) bypass may be necessary to facilitate treatment of unclippable posterior circulation fusiform aneurysms. Although intraoperative digital subtraction angiography (DSA) allows assessment of graft patency, this technique, because of difficulties inherent in performing selective catheterization and angiography in the operating room, has limitations. Duplex sonography, in contrast, is easily performed, and provides information regarding graft patency and blood flow direction during EC-IC bypass procedures. This latter information proved useful in determining the time of parent artery occlusion after two EC-IC bypass procedures performed for treatment of a fusiform midbasilar artery aneurysm.

Bilateral medial medullary infarction due to bilateral vertebral artery dissection.

PubMed

Fukuda, Masafumi; Aiba, Toyotaka; Takahashi, Sho

2004-03-01

We describe a 52-year-old woman who experienced transient motor weakness and numbness of the left extremities and presented 2 days later with severe hemiparesis and sensory impairment of the right extremities and right lingual palsy. Magnetic resonance imaging (MRI) revealed bilateral upper medial medullary infarction, primarily in the left ventral portion. The findings of both three-dimensional (3D) computed tomographic and conventional angiography suggested dissection of both intracranial vertebral arteries (VAs). Medial medullary infarction is generally caused by atherosclerosis within a VA or anterior spinal artery. This is the first report of bilateral medial medullary infarction due to dissection of both intracranial VAs.

Flow Diverters for Intracranial Aneurysms

PubMed Central

Alderazi, Yazan J.; Kass-Hout, Tareq; Prestigiacomo, Charles J.; Gandhi, Chirag D.

2014-01-01

Flow diverters (pipeline embolization device, Silk flow diverter, and Surpass flow diverter) have been developed to treat intracranial aneurysms. These endovascular devices are placed within the parent artery rather than the aneurysm sac. They take advantage of altering hemodynamics at the aneurysm/parent vessel interface, resulting in gradual thrombosis of the aneurysm occurring over time. Subsequent inflammatory response, healing, and endothelial growth shrink the aneurysm and reconstruct the parent artery lumen while preserving perforators and side branches in most cases. Flow diverters have already allowed treatment of previously untreatable wide neck and giant aneurysms. There are risks with flow diverters including in-stent thrombosis, perianeurysmal edema, distant and delayed hemorrhages, and perforator occlusions. Comparative efficacy and safety against other therapies are being studied in ongoing trials. Antiplatelet therapy is mandatory with flow diverters, which has highlighted the need for better evidence for monitoring and tailoring antiplatelet therapy. In this paper we review the devices, their uses, associated complications, evidence base, and ongoing studies. PMID:24967131

The Upper Limit of Cerebral Blood Flow Autoregulation Is Decreased with Elevations in Intracranial Pressure.

PubMed

Pesek, Matthew; Kibler, Kathleen; Easley, R Blaine; Mytar, Jennifer; Rhee, Christopher; Andropolous, Dean; Brady, Ken

2016-01-01

The upper limit of cerebrovascular pressure autoregulation (ULA) is inadequately characterized. We sought to delineate the ULA in a neonatal swine model. Neonatal piglets with sham surgery (n = 9), interventricular fluid infusion (INF; n = 10), controlled cortical impact (CCI; n = 10), or impact + infusion (CCI + INF; n = 11) had intracranial pressure monitoring and bilateral cortical laser-Doppler flux recordings during arterial hypertension until lethality. An increase in red cell flux as a function of cerebral perfusion pressure was determined by piecewise linear regression and static rates of autoregulation (SRoRs) were determined above and below this inflection. When identified, the ULA (median [interquartile range]) was as follows: sham group: 102 mmHg (97-109), INF group: 75 mmHg (52-84), CCI group: 81 mmHg (69-101), and CCI + INF group: 61 mmHg (52-57; p = 0.01). Both groups with interventricular infusion had significantly lower ULA compared with the sham group. Neonatal piglets without intracranial pathological conditions tolerated acute hypertension, with minimal perturbation of cerebral blood flow. Piglets with acutely elevated intracranial pressure, with or without trauma, demonstrated loss of autoregulation when subjected to arterial hypertension.

Effect of Intracranial Stenosis Revascularization on Dynamic and Static Cerebral Autoregulation.

PubMed

Ortega-Gutierrez, Santiago; Samaniego, Edgar A; Huang, Amy; Masurkar, Arjun; Zheng-Lin, Binbin; Derdeyn, Colin P; Hasan, David; Marshall, Randolph; Petersen, Nils

2018-06-01

Severe intracranial stenosis might lead to acute cerebral ischemia. It is imperative to better assess patients who may benefit from immediate reperfusion and blood pressure management to prevent injury to peri-infarct tissue. We assessed cerebral autoregulation using static and dynamic methods in an 81-year-old woman suffering acute cerebral ischemia from severe intracranial stenosis in the petrous segment of the left internal carotid artery (LICA). Static cerebral autoregulation, which is evaluated by magnetic resonance imaging and magnetic resonance perfusion studies showed a progression of infarcts and a large perfusion-diffusion mismatch in the entire LICA territory between the second and third days after onset despite maximized medical therapy. Dynamic methods, including transfer function analysis and mean velocity index, demonstrated an increasingly impaired dynamic cerebral autoregulation (DCA) on the affected side between these days. Revascularization through acute intracranial stenting resulted in improved perfusion in the LICA territory and normalization of both dynamic and static cerebral autoregulation. Thus, DCA, a noninvasive bedside method, may be useful in helping to identify and select patients with large-vessel flow-failure syndromes that would benefit from immediate revascularization of intracranial atherosclerotic disease.

Early retreatment after surgical clipping of ruptured intracranial aneurysms.

PubMed

Ito, Yoshiro; Yamamoto, Tetsuya; Ikeda, Go; Tsuruta, Wataro; Uemura, Kazuya; Komatsu, Yoji; Matsumura, Akira

2017-09-01

Although a rerupture after surgical clipping of ruptured intracranial aneurysms is rare, it is associated with high morbidity and mortality. The causes for retreatment and rupture after surgical clipping are not clearly defined. From a prospectively maintained database of 244 patients who had undergone surgical clipping of ruptured intracranial aneurysms, we selected patients who experienced retreatment or rerupture within 30 days after surgical clipping. Aneurysm occlusions were examined by microvascular Doppler ultrasonography and indocyanine green video-angiography. Indications for retreatment included rerupture and partial occlusion. We analyzed the characteristics and causes of early retreatment. Six patients (2.5%, 95% CI 0.9 to 5.3%) were retreated within 30 days after surgical clipping, including two patients (0.8%, 95% CI 0.1 to 2.9%) who experienced a rerupture. The retreated aneurysms were found in the anterior communicating artery (AcomA) (n = 5) and basilar artery (n = 1). Retreatment of the AcomA (7.5%) was performed significantly more frequently than that of other arteries (0.56%) (p < 0.01). A laterally projected AcomA aneurysm (17.4%) was more frequently retreated than were other aneurysm types (2.3%). Cases of laterally projecting AcomA aneurysms tended to result from an incomplete clip placed using a pterional approach from the opposite side of the aneurysm projection. Despite developments, the rates of retreatment and rerupture after surgical clipping remain similar to those reported previously. Retreatment of the AcomA was significantly more frequent than was retreatment of other arteries. Patients underwent retreatment more frequently when they were originally treated for lateral type aneurysms using a pterional approach from the opposite side of the aneurysm projection. The treatment method and evaluation modalities should be considered carefully for AcomA aneurysms in particular.

RNA interference therapy: a new solution for intracranial atherosclerosis?

PubMed Central

Tang, Tao; Wong, Ka-Sing

2014-01-01

Intracranial atherosclerotic stenosis (ICAS) of a major intracranial artery, especially middle cerebral artery (MCA), is reported to be one leading cause of ischemic stroke throughout the world. Compared with other stroke subtypes, ICAS is associated with a higher risk of recurrent stroke despite aggressive medical therapy. Increased understanding of the pathophysiology of ICAS has highlighted several possible targets for therapeutic interventions. Both luminal stenosis and plaque components of ICAS have been found to be associated with ischemic stroke based a post-mortem study. Recent application of high-resolution magnetic resonance imaging (HRMRI) in evaluating ICAS provides new insight into the vascular biology of plaque morphology and component. High signal on T1-weighted fat-suppressed images (HST1) within MCA plaque of HRMRI, highly suggested of fresh or recent intraplaque hemorrhage, has been found to be associated with ipsilateral brain infarction. Thus, the higher prevalence of intraplaque hemorrhage and neovasculature in symptomatic patients with MCA stenosis may provide a potential target for plaque stabilization. We hypothesize that RNA interference (RNAi) therapy delivered by modified nanoparticles may achieve in vivo biomedical imaging and targeted therapy. With the rapid developments in studies about therapeutic and diagnostic nanomaterials, future studies further exploring the molecular biology of atherosclerosis may provide more drug targets for plaque stabilization. PMID:25333054

The Role of Intraoperative Cerebral Angiography in Transorbital Intracranial Penetrating Trauma: A Case Report and Literature Review.

PubMed

Riley, Jonathan P; Boucher, Andrew B; Kim, Denise S; Barrow, Daniel L; Reynolds, Matthew R

2017-01-01

Transorbital intracranial penetrating trauma with a retained intracranial foreign body is a rare event lacking a widely accepted diagnostic and therapeutic algorithm. Intraoperative catheter angiography (IOA) has been advocated by some authorities to rule out cerebrovascular injury before and/or after removal of the object, but no standard of care currently exists. A 19-year-old man was involved in a construction site accident whereby a framing nail penetrated the left globe, traversed the lateral bony orbit, and terminated in the midtemporal lobe. No hematoma or injury to the middle cerebral arteries (MCAs) was apparent on noncontrast head computed tomography (CT) or CT angiography, respectively. The foreign body was removed in the operating room under direct visualization after a frontotemporal craniotomy without incident. No significant venous or arterial bleeding was encountered. All visualized MCA branches appeared intact. Indocyanine green videoangiography performed immediately after object removal showed adequate filling of the MCA branches. Given these uneventful clinical and radiographic findings, IOA was not performed. Postoperative head CT and CT angiography showed no obvious neurovascular injury. On postoperative day 2, the patient was noted to have an expressive aphasia. Cerebral angiography showed absent antegrade filling of the angular artery with some retrograde perfusion. Magnetic resonance imaging confirmed an ischemic infarction in the midtemporal lobe. The patient's expressive aphasia improved to near baseline during his hospitalization and he made an excellent clinical recovery. In transorbital intracranial penetrating trauma with a retained intracranial object, we advocate microsurgical removal of the object under direct visualization followed immediately by IOA. IOA should be strongly considered even in the setting of minimal intraoperative bleeding and normal findings on videoangiography (a course of action that was not followed in the

Presence of intracranial artery calcification is associated with mortality and vascular events in patients with ischemic stroke after hospital discharge: a cohort study.

PubMed

Bugnicourt, Jean-Marc; Leclercq, Claire; Chillon, Jean-Marc; Diouf, Momar; Deramond, Hervé; Canaple, Sandrine; Lamy, Chantal; Massy, Ziad A; Godefroy, Olivier

2011-12-01

Although intracranial artery calcification (IAC) has been reported to be a risk factor for ischemic stroke, the prognostic implications of IAC in stroke outcome are unknown. The purpose of this study was to determine the association between IAC and risk of vascular events and death in patients with stroke after hospital discharge. All patients with ischemic stroke over a 1-year period were included (n=302). IAC, assessed by multidetector CT, was defined as hyperdense foci (peak density>130 Hounsfield units) and assessed in the 7 major cerebral arteries. The IAC scores ranged from 0 (no calcification) to 7. Follow-up information on major clinical events (including fatal or nonfatal ischemic stroke, cardiac and peripheral artery events, and all-cause death) was obtained by means of a structured phone interview. IAC was present in 260 patients (83%). With a mean follow-up of 773±223 days, 88 major clinical events occurred in 67 patients (22%): 45 new ischemic vascular events (ischemic stroke: n=22; cardiac event: n=15; peripheral artery event: n=8) and 43 deaths from any cause. Patients with the highest IAC scores had significantly higher rates of death and vascular events than those with the lowest IAC scores (log rank test, P=0.029). In the Cox proportional hazards regression model, the IAC score was significantly associated with major clinical events (hazard ratio, 1.34; 95% CI, 1.11-1.61; P=0.002). In patients with ischemic stroke, IAC detection may constitute a simple marker of a high risk of future major clinical events.

Reduced CMRO₂ and cerebrovascular reserve in patients with severe intracranial arterial stenosis: a combined multiparametric qBOLD oxygenation and BOLD fMRI study.

PubMed

Bouvier, Julien; Detante, Olivier; Tahon, Florence; Attye, Arnaud; Perret, Thomas; Chechin, David; Barbieux, Marianne; Boubagra, Kamel; Garambois, Katia; Tropres, Irène; Grand, Sylvie; Barbier, Emmanuel L; Krainik, Alexandre

2015-02-01

Multiparametric quantitative blood oxygenation level dependent (mqBOLD) magnetic resonance Imaging (MRI) approach allows mapping tissular oxygen saturation (StO2 ) and cerebral metabolic rate of oxygen (CMRO2 ). To identify hemodynamic alteration related to severe intracranial arterial stenosis (SIAS), functional MRI of cerebrovascular reserve (CVR BOLD fMRI) to hypercapnia has been proposed. Diffusion imaging suggests chronic low grade ischemia in patients with impaired CVR. The aim of the present study was to evaluate how oxygen parameters (StO2 and CMRO2 ), assessed with mqBOLD approach, correlate with CVR in patients (n = 12) with SIAS and without arterial occlusion. The perfusion (dynamic susceptibility contrast), oxygenation, and CVR were compared. The MRI protocol conducted at 3T lasted approximately 1 h. Regions of interest measures on maps were delineated on segmented gray matter (GM) of middle cerebral artery territories. We have shown that decreased CVR is spatially associated with decreased CMRO2 in GM of patients with SIAS. Further, the degree of ipsilateral CVR reduction was well-correlated with the amplitude of the CMRO2 deficit. The altered CMRO2 suggests the presence of a moderate ischemia explained by both a decrease in perfusion and in CVR. CVR and mqBOLD method may be helpful in the selection of patients with SIAS to advocate for medical therapy or percutaneous transluminal angioplasty-stenting. © 2014 Wiley Periodicals, Inc.

High-sensitive C-reactive protein and dual antiplatelet in intracranial arterial stenosis.

PubMed

Li, Jiejie; Wang, Anxin; Zhao, Xingquan; Liu, Liping; Meng, Xia; Lin, Jinxi; Jing, Jing; Zou, Xinying; Wang, Yilong; Wang, Yongjun

2018-02-06

To determine the relationship of high-sensitive C-reactive protein (hsCRP) and the efficacy and safety of dual antiplatelet therapy in patients with and without intracranial arterial stenosis (ICAS) in the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial. A subgroup of 807 patients with both magnetic resonance angiography images and hsCRP measurement was analyzed. Cox proportional hazards models were used to assess the interaction of hsCRP levels with the effects of dual and single antiplatelet therapy. A total of 358 (44.4%) patients had ICAS and 449 (55.6%) did not. The proportion of patients with elevated hsCRP levels was higher in the ICAS group than in the non-ICAS group (40.2% vs 30.1%, p = 0.003). There was significant interaction between hsCRP and the 2 antiplatelet therapy groups in their effects on recurrent stroke after adjustment for confounding factors in the patients with ICAS ( p = 0.012), but not in those without ( p = 0.256). Compared with aspirin alone, clopidogrel plus aspirin significantly reduced the risk of recurrent stroke only in the patients with ICAS and nonelevated hsCRP levels (adjusted hazard ratio 0.27; 95% confidence interval 0.11 to 0.69; p = 0.006). Similar results were observed for composite vascular events. No significant difference in bleeding was found. Presence of both ICAS and nonelevated hsCRP levels may predict better response to dual antiplatelet therapy in reducing new stroke and composite vascular events in minor stroke or high-risk TIA patients. Further large-scale randomized and controlled clinical trials are needed to confirm this finding. © 2018 American Academy of Neurology.

Solitaire FR stent as an adjunctive tool for pipeline stent deployment in the treatment of giant intracranial aneurysms.

PubMed

Clarençon, Frédéric; Wyse, Gerald; Fanning, Noel; Di Maria, Federico; Gaston, André; Chiras, Jacques; Sourour, Nader

2013-06-01

The use of flow-diverting stents has gained acceptance during the past few years for the treatment of numerous intracranial aneurysms, especially large or giant ones. However, successful catheterization of the distal parent artery in giant intracranial aneurysms with a microcatheter can be extremely challenging. Forming a microcatheter loop in the aneurysm sac can aid distal catheterization. We report the use of a Solitaire FR stent as an adjunctive tool in the successful treatment of 2 giant intracranial unruptured aneurysms with a Pipeline Embolization Device. After having formed a loop inside the aneurysm sac, the microcatheter was anchored distally by a Solitaire FR stent. With the Solitaire FR device opened, the loop in the giant aneurysm sac was completely reduced without loss of the microcatheter position in the distal parent artery. A Pipeline Embolization Device could be delivered in both cases without any difficulty. There were no complications. The technique described results in ideal microcatheter alignment with a secure distal position before deployment of a flow-diverting stent.

No Relation between Body Temperature and Arterial Recanalization at Three Days in Patients with Acute Ischaemic Stroke.

PubMed

Geurts, Marjolein; van der Worp, H Bart; Horsch, Alexander D; Kappelle, L Jaap; Biessels, Geert J; Velthuis, Birgitta K

2015-01-01

Recanalization of an occluded intracranial artery is influenced by temperature-dependent enzymes, including alteplase. We assessed the relation between body temperature on admission and recanalization. We included 278 patients with acute ischaemic stroke within nine hours after symptom onset, who had an intracranial arterial occlusion on admission CT angiography, in 13 participating centres. We calculated the relation per every 0.1°Celsius increase in admission body temperature and recanalization at three days. Recanalization occurred in 80% of occluded arteries. There was no relation between body temperature and recanalization at three days after adjustments for age, NIHSS score on admission and treatment with alteplase (adjusted odds ratio per 0.1°Celsius, 0.99; 95% confidence interval, 0.94-1.05; p = 0.70). Results for patients treated or not treated with alteplase were essentially the same. Our findings suggest that in patients with acute ischaemic stroke there is no relation between body temperature on admission and recanalization of an occluded intracranial artery three days later, irrespective of treatment with alteplase.

No Relation between Body Temperature and Arterial Recanalization at Three Days in Patients with Acute Ischaemic Stroke

PubMed Central

Geurts, Marjolein; van der Worp, H. Bart; Horsch, Alexander D.; Kappelle, L. Jaap; Biessels, Geert J.; Velthuis, Birgitta K.

2015-01-01

Background Recanalization of an occluded intracranial artery is influenced by temperature-dependent enzymes, including alteplase. We assessed the relation between body temperature on admission and recanalization. Methods We included 278 patients with acute ischaemic stroke within nine hours after symptom onset, who had an intracranial arterial occlusion on admission CT angiography, in 13 participating centres. We calculated the relation per every 0.1°Celsius increase in admission body temperature and recanalization at three days. Results Recanalization occurred in 80% of occluded arteries. There was no relation between body temperature and recanalization at three days after adjustments for age, NIHSS score on admission and treatment with alteplase (adjusted odds ratio per 0.1°Celsius, 0.99; 95% confidence interval, 0.94–1.05; p = 0.70). Results for patients treated or not treated with alteplase were essentially the same. Conclusions Our findings suggest that in patients with acute ischaemic stroke there is no relation between body temperature on admission and recanalization of an occluded intracranial artery three days later, irrespective of treatment with alteplase. PMID:26473959

F2-isoprostanes and F4-neuroprostanes as markers of intracranial aneurysm development.

PubMed

Syta-Krzyżanowska, Anna; Jarocka-Karpowicz, Iwona; Kochanowicz, Jan; Turek, Grzegorz; Rutkowski, Robert; Gorbacz, Krzysztof; Mariak, Zenon; Skrzydlewska, Elżbieta

2018-04-24

Intracranial aneurysms are common, occurring in about 1-2% of the population. Saccular aneurysm is a pouch-like pathological dilatation of an intracranial artery that develops when the cerebral artery wall becomes too weak to resist hemodynamic pressure and distends. The aim of this study was to determine whether the development of intracranial aneurysms and subarachnoid hemorrhage (SAH) affects neuronal phospholipid metabolism, and what influence different invasive treatments have on brain free radical phospholipid metabolism. The level of polyunsaturated fatty acid (PUFA) cyclization products - F2-isoprostanes and F4-neuroprostanes - was examined using liquid chromatography - mass spectrometry (LC-MS) in the plasma of patients with brain aneurysm and resulting subarachnoid hemorrhage. It was revealed that an aneurysm leads to the enhancement of lipid peroxidation with a significant increase in plasma F2-isoprostanes and F4-neuroprostanes (more than 3-fold and 11-fold, respectively) in comparison to healthy subjects. The rupture of an aneurysm results in hemorrhage and an additional increase in examined prostaglandin derivatives. The embolization and clipping of aneurysms contribute to a gradual restoration of metabolic homeostasis in brain cells, which is visible in the decrease in PUFA cyclization products. The results indicate that aneurysm development is associated with enhanced inflammation and oxidative stress, factors which favor lipid peroxidation, particularly in neurons, whose membranes are rich in docosahexaenoic acid, a precursor of F4-neuroprostanes.

Comparison of phase-contrast MR imaging and endovascular sonography for intracranial blood flow velocity measurements.

PubMed

Schneiders, J J; Ferns, S P; van Ooij, P; Siebes, M; Nederveen, A J; van den Berg, R; van Lieshout, J; Jansen, G; vanBavel, E; Majoie, C B

2012-10-01

Local hemodynamic information may help to stratify rupture risk of cerebral aneurysms. Patient-specific modeling of cerebral hemodynamics requires accurate data on BFV in perianeurysmal arteries as boundary conditions for CFD. The aim was to compare the BFV measured with PC-MR imaging with that obtained by using intra-arterial Doppler sonography and to determine interpatient variation in intracranial BFV. In 10 patients with unruptured intracranial aneurysms, BFV was measured in the cavernous ICA with PC-MR imaging in conscious patients before treatment, and measured by using an intra-arterial Doppler sonography wire when the patient was anesthetized with either propofol (6 patients) or sevoflurane (4 patients). Both techniques identified a pulsatile blood flow pattern in cerebral arteries. PSV differed >50 cm/s between patients. A mean velocity of 41.3 cm/s (95% CI, 39.3-43.3) was measured with PC-MR imaging. With intra-arterial Doppler sonography, a mean velocity of 29.3 cm/s (95% CI, 25.8-32.8) was measured with the patient under propofol-based intravenous anesthesia. In patients under sevoflurane-based inhaled anesthesia, a mean velocity of 44.9 cm/s (95% CI, 40.6-49.3) was measured. We showed large differences in BFV between patients, emphasizing the importance of using patient-specific hemodynamic boundary conditions in CFD. PC-MR imaging measurements of BFV in conscious patients were comparable with those obtained with the intra-arterial Doppler sonography when the patient was anesthetized with a sevoflurane-based inhaled anesthetic.

Efficacy of stent angioplasty for symptomatic stenoses of the proximal vertebral artery.

PubMed

Weber, W; Mayer, T E; Henkes, H; Kis, B; Hamann, G F; Holtmannspoetter, M; Brueckmann, H; Kuehne, D

2005-11-01

To evaluate the safety and efficacy of stent angioplasty in the treatment of symptomatic arteriosclerotic stenoses of the proximal vertebral artery (VA). Thirty-eight symptomatic stenoses of the vertebral origin were treated with flexible balloon-expandable coronary stents. Angiographic and clinical follow-up examinations were obtained in 26 patients at a mean of 11 months. The immediate post-procedural angiographic results showed no residual stenosis in 33 vessels and mild residual stenoses in five vessels. Periprocedurally, there were two asymptomatic technical complications and one TIA. During follow-up re-stenosis could be detected in 10 cases (36%), and vessel occlusions in two patients. Two stents were broken. One of the restenosis caused a TIA within the follow-up period. Flexible balloon-expandable coronary stents proved to be save and effective in preventing vertebrobasilar stroke but were incapable to preserve the proximal vertebral artery lumen. For the VA origine an adequate stent, self-expanding, bioresorbable, or drug-eluting has to be found.

Analysis of risk factors for perifocal oedema after endovascular embolization of unruptured intracranial arterial aneurysms

PubMed Central

Lukic, Snezana; Jankovic, Slobodan; Popovic, Katarina Surlan; Bankovic, Dragic; Popovic, Peter; Mijailovic, Milan

2015-01-01

Background Endovascular embolization is a treatment of choice for the management of unruptured intracranial aneurysms, but sometimes is complicated with perianeurysmal oedema. The aim of our study was to establish incidence and outcomes of perianeurysmal oedema after endovascular coiling of unruptured intracranial aneurysms, and to reveal possible risk factors for development of this potentially serious complication. Methods In total 119 adult patients with endovascular embolization of unruptured intracranial aneurysm (performed at Department for Interventional Neuroradiology, Clinical Center, Kragujevac, Serbia) were included in our study. The embolizations were made by electrolite-detachable platinum coils: pure platinum, hydrophilic and combination of platinum and hydrophilic coils. Primary outcome variable was perianeurysmal oedema visualized by magnetic resonance imaging (MRI) 7, 30 and 90 days after the embolization. Results The perianurysmal oedema appeared in 47.6% of patients treated with hydrophilic coils, in 21.6% of patients treated with platinum coils, and in 53.8% of those treated with mixed type of the coils. The multivariate logistic regression showed that variables associated with occurrence of perianeurysmal oedema are volume of the aneurysm, hypertension, diabetes and smoking habit. Hypertension is the most important independent predictor of the perianeurysmal oedema, followed by smoking and diabetes. Conclusions The results of our study suggest that older patients with larger unruptured intracranial aneurysms, who suffer from diabetes mellitus and hypertension, and have the smoking habit, are under much higher risk of having perianeurysmal oedema after endovascular coiling. PMID:26834520

Asymptomatic cervicocerebral atherosclerosis, intracranial vascular resistance and cognition: the AsIA-neuropsychology study.

PubMed

López-Olóriz, Jorge; López-Cancio, Elena; Arenillas, Juan F; Hernández, María; Jiménez, Marta; Dorado, Laura; Barrios, Maite; Soriano-Raya, Juan José; Miralbell, Júlia; Cáceres, Cynthia; Forés, Rosa; Pera, Guillem; Dávalos, Antoni; Mataró, Maria

2013-10-01

Carotid atherosclerosis has emerged as a relevant contributor to cognitive impairment and dementia whereas the role of intracranial stenosis and vascular resistance in cognition remains unknown. This study aims to assess the association of asymptomatic cervicocerebral atherosclerosis and intracranial vascular resistance with cognitive performance in a large dementia-free population. The Barcelona-AsIA (Asymptomatic Intracranial Atherosclerosis) Neuropsychology Study included 747 Caucasian subjects older than 50 with a moderate-high vascular risk (assessed by REGICOR score) and without history of neither symptomatic vascular disease nor dementia. Extracranial and transcranial color-coded duplex ultrasound examination was performed to assess carotid intima-media thickness (IMT), presence of carotid plaques (ECAD group), intracranial stenosis (ICAD group), and middle cerebral artery pulsatility index (MCA-PI) as a measure of intracranial vascular resistance. Neuropsychological assessment included tests in three cognitive domains: visuospatial skills and speed, verbal memory and verbal fluency. In univariate analyses, carotid IMT, ECAD and MCA-PI were associated with lower performance in almost all cognitive domains, and ICAD was associated with poor performance in some visuospatial and verbal cognitive tests. After adjustment for age, sex, vascular risk score, years of education and depressive symptoms, ECAD remained associated with poor performance in the three cognitive domains and elevated MCA-PI with worse performance in visuospatial skills and speed. Carotid plaques and increased intracranial vascular resistance are independently associated with low cognitive functioning in Caucasian stroke and dementia-free subjects. We failed to find an independent association of intracranial large vessel stenosis with cognitive performance. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Novel Application of Postmortem CT Angiography for Evaluation of the Intracranial Vascular Anatomy in Cadaver Heads.

PubMed

van Eijk, Ruben P A; van der Zwan, Albert; Bleys, Ronald L A W; Regli, Luca; Esposito, Giuseppe

2015-12-01

Postmortem CT angiography is a common procedure used to visualize the entire human vasculature. For visualization of a specific organ's vascular anatomy, casting is the preferred method. Because of the permanent and damaging nature of casting, the organ cannot be further used as an experimental model after angiography. Therefore, there is a need for a minimally traumatic method to visualize organ-specific vascular anatomy. The purpose of this study was to develop and evaluate a contrast enhancement technique that is capable of visualizing the intracranial vascular anatomy while preserving the anatomic integrity in cadaver heads. Seven human heads were used in this study. Heads were prepared by cannulating the vertebral and internal carotid arteries. Contrast agent was injected as a mixture of tap water, polyethylene glycol 600, and an iodinated contrast agent. Postmortem imaging was executed on a 64-MDCT scanner. Primary image review and 3D reconstruction were performed on a CT workstation. Clear visualization of the major cerebral arteries and smaller intracranial branches was achieved. Adequate visualization was obtained for both the anterior and posterior intracranial circulation. The minimally traumatic angiography method preserved the vascular integrity of the cadaver heads. A novel application of postmortem CT angiography is presented here. The technique can be used for radiologic evaluation of the intracranial circulation in cadaver heads. After CT angiography, the specimen can be used for further experimental or laboratory testing and teaching purposes.

Evolution of intracranial atherosclerotic disease under modern medical therapy.

PubMed

Leung, Thomas W; Wang, Lily; Soo, Yannie O Y; Ip, Vincent H L; Chan, Anne Y Y; Au, Lisa W C; Fan, Florence S Y; Lau, Alex Y L; Leung, Howan; Abrigo, Jill; Wong, Adrian; Mok, Vincent C T; Ng, Ping Wing; Tsoi, Tak Hong; Li, Siu Hung; Man, Celeste B L; Fong, Wing Chi; Wong, Ka Sing; Yu, Simon C H

2015-03-01

Understanding how symptomatic intracranial atherosclerotic disease (ICAD) evolves with current medical therapy may inform secondary stroke prevention. In a prospective academic-initiated study, we recruited 50 patients (mean age = 63.4 ± 9.0 years) with acute strokes attributed to high-grade (≥70%) intracranial atherosclerotic stenosis for 3-dimensional rotational angiograms before and after intensive medical therapy for 12 months. Treatment targets included low-density lipoprotein ≤ 70mg/dl, glycosylated hemoglobin (HbA1c) ≤ 6.5%, and systolic blood pressure ≤ 140 mmHg. We analyzed infarct topography and monitored microembolic signal in recurrent strokes. The reference group was a published cohort of 143 ICAD patients. Overall, the stenoses regressed from 79% at baseline (interquartile range [IQR] = 71-87%) to 63% (IQR = 54-74%) in 1 year (p < 0.001). Specifically, the qualifying lesions (n = 49) regressed (stenosis reduced >10%) in 24 patients (49%), remained quiescent (stenosis same or ±10%) in 21 patients (43%), and progressed (stenosis increased >10%) in 4 patients (8%). There was no difference in intensity of risk factor control between groups of diverging clinical or angiographic outcomes. Higher HbA1c at baseline predicted plaque regression at 1 year (odds ratio = 4.4, 95% confidence interval = 1.4-14.5, p = 0.006). Among the 6 patients with recurrent strokes pertaining to the qualifying stenosis, 5 patients had solitary or rosarylike acute infarcts along the internal or anterior border zones, and 2 patients showed microembolic signals in transcranial Doppler ultrasound. A majority of symptomatic high-grade intracranial plaques had regressed or remained quiescent by 12 months under intensive medical therapy. Artery-to-artery thromboembolism with impaired washout at border zones was a common mechanism in stroke recurrence. © 2014 American Neurological Association.

Management of Intracranial Hypertension

PubMed Central

Rangel-Castillo, Leonardo; Gopinath, Shankar; Robertson, Claudia S.

2008-01-01

Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury. PMID:18514825

Validation of a basic neurosonology laboratory for detecting cervical carotid artery stenosis.

PubMed

de la Cruz Cosme, C; Dawid Milner, M S; Ojeda Burgos, G; Gallardo Tur, A; Márquez Martínez, M; Segura, T

2017-03-24

Most of the cases of ischaemic stroke in our setting are of atherothrombotic origin. Detecting intracranial and cervical carotid artery stenosis in patients with ischaemic stroke is therefore essential. Ultrasonography has become the tool of choice for diagnosing carotid artery stenosis because it is both readily accessibility and reliable. However, use of this technique must be validated in each laboratory. The purpose of this study is to validate Doppler ultrasound in our laboratory as a means of detecting severe carotid artery stenosis. We conducted an observational descriptive study to evaluate diagnostic tests. The results from transcranial and cervical carotid Doppler ultrasound scans conducted by neurologists were compared to those from carotid duplex scans performed by radiologists in patients diagnosed with stroke. Arteriography was considered the gold standard (MR angiography, CT angiography, or conventional arteriography). Our sample included 228 patients. Transcranial and cervical carotid Doppler ultrasound showed a sensitivity of 95% and specificity of 100% for detection of carotid artery stenosis > 70%, whereas carotid duplex displayed a sensitivity of 87% and a specificity of 94%. Transcranial carotid Doppler ultrasound achieved a sensitivity of 78% and a specificity of 98% for detection of intracranial stenosis. Doppler ultrasound in our neurosonology laboratory was found to be a useful diagnostic tool for detecting cervical carotid artery stenosis and demonstrated superiority to carotid duplex despite the lack of B-mode. Furthermore, this technique was found to be useful for detecting intracranial stenosis. Copyright © 2017 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.

Indications and applications of arterial stents for stroke prevention in atherosclerotic intracranial stenosis.

PubMed

Fields, Jeremy D; Liu, Kenneth C; Barnwell, Stanley L; Clark, Wayne M; Lutsep, Helmi L

2010-01-01

Intracranial stenosis accounts for 8-10% of all ischemic strokes in North America, a frequency slightly less than that of extracranial carotid stenosis. Among patients presenting with transient ischemic attack or stroke due to intracranial stenosis, the risk of recurrent stroke in the first year after initial symptoms is about 14%. Those with high-risk features (recent stroke and severe stenosis) have up to a 23% rate of recurrent stroke in the year after their initial event. Angioplasty with stenting has emerged as a potential treatment strategy, particularly in high-risk patients, although evidence is currently limited to uncontrolled prospective trials and retrospective case series. In this article, we critically review the clinical results supporting the use of stenting and highlight some key considerations in the application of this technology, including patient selection, procedural management, technical issues, and risk factors for complications and in-stent restenosis.

China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS): A new, prospective, multicenter, randomized controlled trial in China

PubMed Central

Gao, Peng; Zhao, Zhenwei; Wang, Daming; Wu, Jian; Cai, Yiling; Li, Tianxiao; Wu, Wei; Shi, Huaizhang; He, Weiwen; Zhu, Fengshui; Ling, Feng

2015-01-01

Background Patients with symptomatic stenosis of intradural arteries are at high risk for subsequent stroke. Since the SAMMPRIS trial, stenting is no longer recommended as primary treatment; however, the results of this trial, its inclusion criteria and its center selection received significant criticism and did not appear to reflect our experience regarding natural history nor treatment complications rate. As intracranial atherosclerosis (ICAS) is the most common cause for stroke in Asian countries, we are hereby proposing a refined prospective, randomized, multicenter study in an Asian population with strictly defined patient and participating center inclusion criteria. Methods The China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS) trial is an ongoing, government-funded, prospective, multicenter, randomized trial. It recruits patients with recent TIA or stroke caused by 70%–99% stenosis of a major intracranial artery. Patients with previous stroke related to perforator ischemia will not be included. Only high-volume centers with a proven track record will enroll patients as determined by a lead-in phase. Patients will be randomized (1:1) to best medical therapy alone or medical therapy plus stenting. Primary endpoints are any stroke or death within 30 days after enrollment or after any revascularization procedure of the qualifying lesion during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days. The CASSISS trial will be conducted in eight sites in China with core imaging lab review at a North American site and aims to have a sample size of 380 participants (stenting, 190; medical therapy, 190). Recruitment is expected to be finished by December 2016. Patients will be followed for at least three years. The trial is scheduled to complete in 2019. Conclusion In the proposed trial, certain shortcomings of SAMMPRIS including patient and participating center selection will be addressed. The

Wall shear stress in intracranial aneurysms and adjacent arteries☆

PubMed Central

Wang, Fuyu; Xu, Bainan; Sun, Zhenghui; Wu, Chen; Zhang, Xiaojun

2013-01-01

Hemodynamic parameters play an important role in aneurysm formation and growth. However, it is difficult to directly observe a rapidly growing de novo aneurysm in a patient. To investigate possible associations between hemodynamic parameters and the formation and growth of intracranial aneurysms, the present study constructed a computational model of a case with an internal carotid artery aneurysm and an anterior communicating artery aneurysm, based on the CT angiography findings of a patient. To simulate the formation of the anterior communicating artery aneurysm and the growth of the internal carotid artery aneurysm, we then constructed a model that virtually removed the anterior communicating artery aneurysm, and a further two models that also progressively decreased the size of the internal carotid artery aneurysm. Computational simulations of the fluid dynamics of the four models were performed under pulsatile flow conditions, and wall shear stress was compared among the different models. In the three aneurysm growth models, increasing size of the aneurysm was associated with an increased area of low wall shear stress, a significant decrease in wall shear stress at the dome of the aneurysm, and a significant change in the wall shear stress of the parent artery. The wall shear stress of the anterior communicating artery remained low, and was significantly lower than the wall shear stress at the bifurcation of the internal carotid artery or the bifurcation of the middle cerebral artery. After formation of the anterior communicating artery aneurysm, the wall shear stress at the dome of the internal carotid artery aneurysm increased significantly, and the wall shear stress in the upstream arteries also changed significantly. These findings indicate that low wall shear stress may be associated with the initiation and growth of aneurysms, and that aneurysm formation and growth may influence hemodynamic parameters in the local and adjacent arteries. PMID:25206394

[Revascularization of the carotid and vertebral arteries in the elderly].

PubMed

Illuminati, G; Bezzi, M; D'Urso, A; Giacobbi, D; Ceccanei, G; Vietri, F

2004-01-01

From January 1994 to July 2004, 323 patients underwent 348 revascularization of carotid bifurcation for atherosclerotic stenoses. Eighty eight patients (group A) were 75 year-old or older, whereas 235 (group B) were younger than 75 years. Postoperative mortality/neurologic morbidity rate was 1% in group A, and 1.4% in group B. At 5 years, patency and freedom from symptoms/stroke were, respectively, 91% and 92% in group A, and 89% and 91% in group B. None of these differences was statistically significant. In the same time period, 26 internal carotid arteries were revascularized in 24 patients, 75 or more aged, for a symptomatic kinking. Postoperative mortality/morbidity rate was absent, whereas, at 5 years, patency and freedom from symptoms/stroke were, respectively, 88% and 92%. Twelve vertebral arteries were revascularized in 12 patients, 75 or more aged, for invalidating symptoms of vertebrobasilar insufficiency. Postoperative mortality/neurologic morbidity rate was absent. In one case postoperative recurrence of symptoms occurred, despite a patent revascularization. Patency and freedom from symptoms/stroke were 84% and 75%, at 5 years. Revascularization of carotid and vertebral arteries in the elderly can be accomplished with good results, superposable to those of standard revascularization of carotid bifurcation in a younger patients' population.

Recanalization Results After Intracranial Stenting of Atherosclerotic Stenoses

DOE Office of Scientific and Technical Information (OSTI.GOV)

Blasel, Stella, E-mail: Stella.Blasel@kgu.de; Yuekzek, Zeynep; Kurre, Wiebke

2010-10-15

The purpose of this investigation was to provide a detailed description of the angiographic results after stenting of high-grade intracranial stenosis using balloon-expandable stents. Forty consecutive patients with symptomatic atherosclerotic intracranial stenosis >50% received endovascular treatment by placement of balloon-expandable stents using the concept of slight underdilation and strict avoidance of overdilation. Intra-arterial digital subtraction angiography images before and after stenting in the same projection were reviewed for pre- and post-therapeutic measurement of the degree of stenosis and evaluation of morphologic criteria like plaque coverage, stent apposition, patency of side branches, and signs of dissection or vasospasm. Stenting decreased themore » mean percentage stenosis from 76.2 (WASID criteria) to 20.8%. Residual stenosis ranged from 0 to 55% with residual stenosis >50% in two of 40 cases. Technical success rate was 95%. There were no major vessel complications, but minor abnormalities like incomplete stent apposition (8/40) or plaque coverage (7/40), incomplete filling of side branches (13/40), and minor dissections after stenting (2/40) were seen. One case with incomplete stent apposition and two cases with side branch compromise were associated with clinical symptoms. In conclusion, intracranial stenting with slight underdilation avoided major vessel complication and created reliable luminal gain. Suboptimal recanalization results were frequently detected and may be the source of neurological complications in individual cases.« less

Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury.

PubMed

Güiza, Fabian; Depreitere, Bart; Piper, Ian; Citerio, Giuseppe; Chambers, Iain; Jones, Patricia A; Lo, Tsz-Yan Milly; Enblad, Per; Nillson, Pelle; Feyen, Bart; Jorens, Philippe; Maas, Andrew; Schuhmann, Martin U; Donald, Rob; Moss, Laura; Van den Berghe, Greet; Meyfroidt, Geert

2015-06-01

To assess the impact of the duration and intensity of episodes of increased intracranial pressure on 6-month neurological outcome in adult and paediatric traumatic brain injury. Analysis of prospectively collected minute-by-minute intracranial pressure and mean arterial blood pressure data of 261 adult and 99 paediatric traumatic brain injury patients from multiple European centres. The relationship of episodes of elevated intracranial pressure (defined as a pressure above a certain threshold during a certain time) with 6-month Glasgow Outcome Scale was visualized in a colour-coded plot. The colour-coded plot illustrates the intuitive concept that episodes of higher intracranial pressure can only be tolerated for shorter durations: the curve that delineates the duration and intensity of those intracranial pressure episodes associated with worse outcome is an approximately exponential decay curve. In children, the curve resembles that of adults, but the delineation between episodes associated with worse outcome occurs at lower intracranial pressure thresholds. Intracranial pressures above 20 mmHg lasting longer than 37 min in adults, and longer than 8 min in children, are associated with worse outcomes. In a multivariate model, together with known baseline risk factors for outcome in severe traumatic brain injury, the cumulative intracranial pressure-time burden is independently associated with mortality. When cerebrovascular autoregulation, assessed with the low-frequency autoregulation index, is impaired, the ability to tolerate elevated intracranial pressures is reduced. When the cerebral perfusion pressure is below 50 mmHg, all intracranial pressure insults, regardless of duration, are associated with worse outcome. The intracranial pressure-time burden associated with worse outcome is visualised in a colour-coded plot. In children, secondary injury occurs at lower intracranial pressure thresholds as compared to adults. Impaired cerebrovascular

Pathophysiology and management of intracranial arterial stenosis around the circle of Willis associated with hyperthyroidism: case reports and literature review.

PubMed

Matano, Fumihiro; Murai, Yasuo; Adachi, Koji; Kitamura, Takayuki; Teramoto, Akira

2014-04-01

Cases of moyamoya disease or intracranial arterial stenosis around the circle of Willis (M/IAS) associated with hyperthyroidism have been reported. However, most of these previous reports were of the ischemic form of M/IAS and primary hyperthyroidism. To the best of our knowledge, no studies have documented therapy for M/IAS associated with hyperthyroidism. We discuss four previously unreported cases, including those involving the intracerebral hemorrhage form and thyroid-stimulating hormone (TSH) secretion from a pituitary adenoma (secondary hyperthyroidism). We analyzed data from 52 previously reported cases, including the 4 cases presented here, and discuss M/IAS associated with hyperthyroidism, treatment options, pathophysiology, the ischemic and hemorrhagic forms, secondary hyperthyroidism, and the relevant literature. Hyperthyroidism results in thyrotoxicosis and the stimulation of the superior cervical ganglion by TSH antibodies and f-T3/f-T4. Consequently, hypercoagulability and stenosis of the cerebral artery can occur. There are many reports of ischemic M/IAS associated with hyperthyroidism. A conservative approach to treatment is important in such cases; for example, antithyroid therapy should be the first choice to treat ischemic M/IAS. There have been only a limited number of reports on hemorrhagic M/IAS. We presume that hemorrhagic M/IAS tears the weakened vasculature in a manner similar to that of normal M/IAS (with no complicating hyperthyroidism). The authors also reported M/IAS associated with secondary hyperthyroidism due to pituitary thyroid secreting hormone secreting adenoma.

Intracranial pressure after subarachnoid hemorrhage.

PubMed

Zoerle, Tommaso; Lombardo, Alessandra; Colombo, Angelo; Longhi, Luca; Zanier, Elisa R; Rampini, Paolo; Stocchetti, Nino

2015-01-01

To describe mean intracranial pressure after aneurysmal subarachnoid hemorrhage, to identify clinical factors associated with increased mean intracranial pressure, and to explore the relationship between mean intracranial pressure and outcome. Analysis of a prospectively collected observational database. Neuroscience ICU of an academic hospital. One hundred sixteen patients with subarachnoid hemorrhage and intracranial pressure monitoring. None. Episodes of intracranial pressure greater than 20 mm Hg lasting at least 5 minutes and the mean intracranial pressure for every 12-hour interval were analyzed. The highest mean intracranial pressure was analyzed in relation to demographic characteristics, acute neurologic status, initial radiological findings, aneurysm treatment, clinical vasospasm, and ischemic lesion. Mortality and 6-month outcome (evaluated using a dichotomized Glasgow Outcome Scale) were also introduced in multivariable logistic models. Eighty-one percent of patients had at least one episode of high intracranial pressure and 36% had a highest mean intracranial pressure more than 20 mm Hg. The number of patients with high intracranial pressure peaked 3 days after subarachnoid hemorrhage and declined after day 7. Highest mean intracranial pressure greater than 20 mm Hg was significantly associated with initial neurologic status, aneurysmal rebleeding, amount of blood on CT scan, and ischemic lesion within 72 hours from subarachnoid hemorrhage. Patients with highest mean intracranial pressure greater than 20 mm Hg had significantly higher mortality. When death, vegetative state, and severe disability at 6 months were pooled, however, intracranial pressure was not an independent predictor of unfavorable outcome. High intracranial pressure is a common complication in the first week after subarachnoid hemorrhage in severe cases admitted to ICU. Mean intracranial pressure is associated with the severity of early brain injury and with mortality.

Four-Dimensional Flow MRI Analysis of Cerebral Blood Flow Before and After High-Flow Extracranial-Intracranial Bypass Surgery With Internal Carotid Artery Ligation.

PubMed

Orita, Erika; Murai, Yasuo; Sekine, Tetsuro; Takagi, Ryo; Amano, Yasuo; Ando, Takahiro; Iwata, Kotomi; Obara, Makoto; Kumita, Shinichiro

2018-05-11

The hemodynamic changes that occur after high-flow (extracranial-intracranial) EC-IC bypass surgery with internal carotid artery (ICA) ligation are not well known. To assess blood flow changes after high-flow EC-IC bypass with ICA ligation by time-resolved 3-dimensional phase-contrast (4D Flow) magnetic resonance imaging (MRI). We enrolled 11 patients who underwent high-flow EC-IC bypass. 4D Flow MRI was performed before and after surgery to quantify the blood flow volume (BFV) of the ipsilateral ICA (BFViICA), bypass artery (BFVbypass), contralateral ICA (BFVcICA), and basilar artery (BFVBA). Subsequently, we calculated the total BFV (BFVtotal = BFViICA + BFVcICA + BFVBA [before surgery], BFVcICA + BFVBA + BFVbypass [after surgery]). The BFV changes after bypass was statistically analyzed. BFVbypass was slightly lower than BFViICA, but the difference was not statistically significant (3.84 ± 0.94 vs 4.42 ± 1.38 mL/s). The BFVcICA and BFVBA significantly increased after bypass surgery (BFVcICA 5.89 ± 1.44 vs 7.22 ± 1.37 mL/s [P = .0018], BFVBA 3.06 ± 0.41 vs 4.12 ± 0.38 mL/s [P < .001]). The BFVtotal significantly increased after surgery (13.37 ± 2.58 vs 15.18 ± 1.77 mL/s [P = .015]). There was no evidence of hyperperfusion syndrome in any cases. After high-flow EC-IC bypass with permanent ICA ligation, the bypass artery could partially compensate for the loss of BFV of the sacrificed ICA. The increased flow of the contralateral ICA and BA supply collateral blood flow. Clinically irrelevant hyperperfusion was observed.

Estimation of Hidden State Variables of the Intracranial System Using Constrained Nonlinear Kalman Filters

PubMed Central

Nenov, Valeriy; Bergsneider, Marvin; Glenn, Thomas C.; Vespa, Paul; Martin, Neil

2007-01-01

Impeded by the rigid skull, assessment of physiological variables of the intracranial system is difficult. A hidden state estimation approach is used in the present work to facilitate the estimation of unobserved variables from available clinical measurements including intracranial pressure (ICP) and cerebral blood flow velocity (CBFV). The estimation algorithm is based on a modified nonlinear intracranial mathematical model, whose parameters are first identified in an offline stage using a nonlinear optimization paradigm. Following the offline stage, an online filtering process is performed using a nonlinear Kalman filter (KF)-like state estimator that is equipped with a new way of deriving the Kalman gain satisfying the physiological constraints on the state variables. The proposed method is then validated by comparing different state estimation methods and input/output (I/O) configurations using simulated data. It is also applied to a set of CBFV, ICP and arterial blood pressure (ABP) signal segments from brain injury patients. The results indicated that the proposed constrained nonlinear KF achieved the best performance among the evaluated state estimators and that the state estimator combined with the I/O configuration that has ICP as the measured output can potentially be used to estimate CBFV continuously. Finally, the state estimator combined with the I/O configuration that has both ICP and CBFV as outputs can potentially estimate the lumped cerebral arterial radii, which are not measurable in a typical clinical environment. PMID:17281533

Multiscale modeling of the human arterial tree on the TeraGrid.

NASA Astrophysics Data System (ADS)

Karniadakis, Gerorge

2009-03-01

A multiscale model of the human arterial tree will be presented consisting of the macrovascular network (MaN, arteries above 1-2 mm), the mesovascular network (MeN, arterioles above 10 micro-m) and the microvascular network (MiN, capillaries). Coupling conditions between the MaN-MeN-MiN will be discussed and three different methods in modeling each network will be presented. Specific examples will be shown for the intracranial arterial tree for healthy subjects but also for patients with hydrocephalus.

Microneurosurgical management of anterior choroid artery aneurysms.

PubMed

Lehecka, Martin; Dashti, Reza; Laakso, Aki; van Popta, Jouke S; Romani, Rossana; Navratil, Ondrej; Kivipelto, Leena; Kivisaari, Riku; Foroughi, Mansoor; Kokuzawa, Jouji; Lehto, Hanna; Niemelä, Mika; Rinne, Jaakko; Ronkainen, Antti; Koivisto, Timo; Jääskelainen, Juha E; Hernesniemi, Juha

2010-05-01

Anterior choroid artery aneurysms (AChAAs) constitute 2%-5% of all intracranial aneurysms. They are usually small, thin walled with one or several arteries originating at their base, and often associated with multiple aneurysms. In this article, we review the practical microsurgical anatomy, the preoperative imaging, surgical planning, and the microneurosurgical steps in the dissection and the clipping of AChAAs. This review, and the whole series on intracranial aneurysms (IAs), are mainly based on the personal microneurosurgical experience of the senior author (J.H.) in two Finnish centers (Helsinki and Kuopio) that serve, without patient selection, the catchment area in Southern and Eastern Finland. These two centers have treated more than 10,000 patients with IAs since 1951. In the Kuopio Cerebral Aneurysm Database of 3005 patients with 4253 IAs, 831 patients (28%) had altogether 980 internal carotid artery (ICA) aneurysms, of whom 95 patients had 99 (2%) AChAAs. Ruptured AChAAs, found in 39 patients (41%), with median size of 6 mm (range = 2-19 mm), were associated with intracerebral hematoma (ICH) in only 1 (3%) patient. Multiple aneurysms were seen in 58 (61%) patients. The main difficulty in microneurosurgical management of AChAAs is to preserve flow in the anterior choroid artery originating at the base and often attached to the aneurysm dome. This necessitates perfect surgical strategy based on preoperative knowledge of 3 dimensional angioarchitecture and proper orientation during the microsurgical dissection. Copyright © 2010 Elsevier Inc. All rights reserved.

Prevalence and long-term clinical significance of intracranial atherosclerosis after ischaemic stroke or transient ischaemic attack: a cohort study.

PubMed

Ovesen, Christian; Abild, Annemette; Christensen, Anders Fogh; Rosenbaum, Sverre; Hansen, Christine Krarup; Havsteen, Inger; Nielsen, Jens Kellberg; Christensen, Hanne

2013-10-21

We investigated the prevalence and long-term risk associated with intracranial atherosclerosis identified during routine evaluation. This study presents data from a prospective cohort of patients admitted to our stroke unit for thrombolysis evaluation. We included 652 with a final diagnosis of ischaemic stroke or transient ischaemic attack (TIA) from April 2009 to December 2011. All patients were acutely evaluated with cerebral CT and CT angiography (CTA). Acute radiological examinations were screened for intracranial arterial stenosis (IAS) or intracranial arterial calcifications (IAC). Intracranial stenosis was grouped into 30-50%, 50-70% and >70% lumen reduction. The extent of IAC was graded as number of vessels affected. Patients were followed until July 2013. Recurrence of an ischaemic event (stroke, ischaemic heart disease (IHD) and TIA) was documented through the national chart system. Poor outcome was defined as death or recurrence of ischaemic event. 101 (15.5%) patients showed IAS (70: 30-50%, 29: 50-70% and 16: >70%). Two-hundred and fifteen (33%) patients had no IAC, 339 (52%) in 1-2 vessels and 102 (16%) in >2 vessels. During follow-up, 53 strokes, 20 TIA and 14 IHD occurred, and 95 patients died. The risk of poor outcome was significantly different among different extents of IAS as well as IAC (log-rank test p<0.01 for both). In unadjusted analysis IAS and IAC predicted poor outcome and recurrent ischaemic event. When adjusted, IAS and IAC independently increased the risk of a recurrent ischaemic event (IAS: HR 1.67; CI 1.04 to 2.64 and IAC: HR 1.22; CI 1.02 to 1.47). Intracranial atherosclerosis detected during acute evaluation predicts an increased risk of recurrent stroke.

Factors influencing intracranial vessel densities on unenhanced computed tomography: differences between hemispheres.

PubMed

Grams, Astrid E; Rehwald, Rafael; Schmittnägel, Charlotte; Schmidt, Thorsten; Tanislav, Christian; Berghoff, Martin; Krombach, Gabriele A; Moritz, Regina; Obert, Martin; Gizewski, Elke R; Glodny, Bernhard

The aim was to identify the factors influencing intracranial vessel density (VD). The Hounsfield units of the dense vessel and the contralateral side were measured in 34 patients with arterial clots, 20 with venous clots, and 196 without clots and correlated with skull thickness, density and dimensions, gender, age, red blood cell count (RBC), hemoglobin (HB), hematocrit (HT), creatinine, and sodium. Positive correlations were found between VD and HT, RBC, HB, creatinine, and occipital bone density. Density differences between the right and left intracranial vessels were more accurate (sensitivity/specificity/accuracy=0.91/0.93/0.93 and 0.75/0.87/0.85, respectively) for detecting clots than VD alone. HT, RBC, and HB are the main factors that correlate with VD. Copyright © 2016 Elsevier Inc. All rights reserved.

Anatomical Variability of the Posterior Communicating Artery.

PubMed

Gunnal, Sandhya Arvind; Farooqui, Mujibuddin S; Wabale, Rajendra N

2018-01-01

Although posterior communicating artery (PCoA) is a smaller branch of the internal carotid artery, it gives the main contribution in the formation of circle of Willis (CW) by communicating with the internal carotid arterial system and the vertebro-basilar arterial system. The size of PCoA varies frequently. The present work aims to study the PCoA regarding its morphology, morphometry, and symmetry. This study was conducted on 170 human cadaveric brains. Brains were dissected carefully and delicately to expose all components of CW, especially PCoA. Morphological variations of PCoA were noted along with its morphometry and symmetry. Morphological variations of PCoA were aplasia (3.52%), hypoplasia (25.29%), fenestration (0.58%), and persistent fetal pattern (16.47%). In the present study, we found the five different types of terminations of PCoA. Type I termination was the most common type, seen in 92.94% of cases, Type II termination was seen in 1.17%, Type III and Type IV terminations both were seen in 0.58%, and Type V was seen in 1.17%. The mean length of PCoA was 15.9 mm and 15.3 mm on the right and left sides, respectively. The mean diameter of PCoA was 2.1 mm and 1.9 mm on the right and left sides, respectively. Symmetry of PCoA was seen in 65.29% and asymmetric PCoA was seen in 34.70% of cases. The present study provides the complete description of PCoA regarding its morphology, symmetry, and morphometry. Awareness of these anatomical variations is important in neurovascular procedures.

Anatomical Variability of the Posterior Communicating Artery

PubMed Central

Gunnal, Sandhya Arvind; Farooqui, Mujibuddin S.; Wabale, Rajendra N.

2018-01-01

Objective: Although posterior communicating artery (PCoA) is a smaller branch of the internal carotid artery, it gives the main contribution in the formation of circle of Willis (CW) by communicating with the internal carotid arterial system and the vertebro-basilar arterial system. The size of PCoA varies frequently. The present work aims to study the PCoA regarding its morphology, morphometry, and symmetry. Materials and Methods: This study was conducted on 170 human cadaveric brains. Brains were dissected carefully and delicately to expose all components of CW, especially PCoA. Morphological variations of PCoA were noted along with its morphometry and symmetry. Results: Morphological variations of PCoA were aplasia (3.52%), hypoplasia (25.29%), fenestration (0.58%), and persistent fetal pattern (16.47%). In the present study, we found the five different types of terminations of PCoA. Type I termination was the most common type, seen in 92.94% of cases, Type II termination was seen in 1.17%, Type III and Type IV terminations both were seen in 0.58%, and Type V was seen in 1.17%. The mean length of PCoA was 15.9 mm and 15.3 mm on the right and left sides, respectively. The mean diameter of PCoA was 2.1 mm and 1.9 mm on the right and left sides, respectively. Symmetry of PCoA was seen in 65.29% and asymmetric PCoA was seen in 34.70% of cases. Conclusion: The present study provides the complete description of PCoA regarding its morphology, symmetry, and morphometry. Awareness of these anatomical variations is important in neurovascular procedures. PMID:29682035

Neuroblastoma with intracranial involvement: an ENSG Study.

PubMed

Shaw, P J; Eden, T

1992-01-01

We report the experience of the European Neuroblastoma Study Group (ENSG) with central nervous system (CNS) involvement of neuroblastoma. Among this series of intensively treated patients, CNS neuroblastoma was diagnosed by computerised tomography (CT) scanning, rather than by autopsy. Cranial disease occurred in 5% of ENSG patients. Of 11 patients with intracranial disease, 4 had disease in the posterior fossa, a site rarely reported previously. Furthermore, 5 cases had CNS metastases at a time when there was no detectable disease elsewhere, rather than as part of extensive relapse. The pattern of disease we observed, at least for those with parenchymal disease, is in keeping with arterial spread. Although CT scanning is the optimal modality for identifying CNS disease, 2 cases had normal head CT scans prior to the onset of CNS disease. As most patients had symptoms of raised intracranial pressure (RICP) at the time the CNS disease was diagnosed, there does not seem to be any indication for routine CT scanning of the head at diagnosis, but this should be performed as soon as any symptoms or signs appear. With patients living longer with their disease, vigilance must be maintained during follow-up.

Coil Embolization for Intracranial Aneurysms

PubMed Central

2006-01-01

Executive Summary Objective To determine the effectiveness and cost-effectiveness of coil embolization compared with surgical clipping to treat intracranial aneurysms. The Technology Endovascular coil embolization is a percutaneous approach to treat an intracranial aneurysm from within the blood vessel without the need of a craniotomy. In this procedure, a microcatheter is inserted into the femoral artery near the groin and navigated to the site of the aneurysm. Small helical platinum coils are deployed through the microcatheter to fill the aneurysm, and prevent it from further expansion and rupture. Health Canada has approved numerous types of coils and coil delivery systems to treat intracranial aneurysms. The most favoured are controlled detachable coils. Coil embolization may be used with other adjunct endovascular devices such as stents and balloons. Background Intracranial Aneurysms Intracranial aneurysms are the dilation or ballooning of part of a blood vessel in the brain. Intracranial aneurysms range in size from small (<12 mm in diameter) to large (12–25 mm), and to giant (>25 mm). There are 3 main types of aneurysms. Fusiform aneurysms involve the entire circumference of the artery; saccular aneurysms have outpouchings; and dissecting aneurysms have tears in the arterial wall. Berry aneurysms are saccular aneurysms with well-defined necks. Intracranial aneurysms may occur in any blood vessel of the brain; however, they are most commonly found at the branch points of large arteries that form the circle of Willis at the base of the brain. In 85% to 95% of patients, they are found in the anterior circulation. Aneurysms in the posterior circulation are less frequent, and are more difficult to treat surgically due to inaccessibility. Most intracranial aneurysms are small and asymptomatic. Large aneurysms may have a mass effect, causing compression on the brain and cranial nerves and neurological deficits. When an intracranial aneurysm ruptures and bleeds

Dangerous extracranial-intracranial anastomoses and supply to the cranial nerves: vessels the neurointerventionalist needs to know.

PubMed

Geibprasert, S; Pongpech, S; Armstrong, D; Krings, T

2009-09-01

Transarterial embolization in the external carotid artery (ECA) territory has a major role in the endovascular management of epistaxis, skull base tumors, and dural arteriovenous fistulas. Knowledge of the potential anastomotic routes, identification of the cranial nerve supply from the ECA, and the proper choice of embolic material are crucial to help the interventionalist avoid neurologic complications during the procedure. Three regions along the skull base constitute potential anastomotic routes between the extracranial and intracranial arteries: the orbital, the petrocavernous, and the upper cervical regions. Branches of the internal maxillary artery have anastomoses with the ophthalmic artery and petrocavernous internal carotid artery (ICA), whereas the branches of the ascending pharyngeal artery are connected to the petrocavernous ICA. Branches of both the ascending pharyngeal artery and the occipital artery have anastomoses with the vertebral artery. To avoid cranial nerve palsy, one must have knowledge of the supply to the lower cranial nerves: The petrous branch of the middle meningeal artery and the stylomastoid branch of the posterior auricular artery form the facial arcade as the major supply to the facial nerve, and the neuromeningeal trunk of the ascending pharyngeal artery supplies the lower cranial nerves (CN IX-XII).

Endovascular treatment of bifurcation intracranial aneurysms with the WEB SL/SLS: 6-month clinical and angiographic results

PubMed Central

Bozzetto Ambrosi, Patricia; Sivan-Hoffmann, Rotem; Riva, Roberto; Signorelli, Francesco; Labeyrie, Paul-Emile; Eldesouky, Islam; Sadeh-Gonike, Udi; Armoiry, Xavier; Turjman, Francis

2015-01-01

Background The WEB device is a recent intrasaccular flow disruption technique developed for the treatment of wide-necked intracranial aneurysms. To date, a single report on the WEB Single-Layer (SL) treatment of intracranial aneurysms has been published with 1-months' safety results. The aim of this study is to report our experience and 6-month clinical and angiographic follow-up of endovascular treatment of wide-neck aneurysm with the WEB SL. Methods Ten patients with 10 unruptured wide-necked aneurysms were prospectively enrolled in this study. Feasibility, intraoperative and postoperative complications, and outcomes were recorded. Immediate and 6-month clinical and angiographic results were evaluated. Results Failure of WEB SL placement occurred in two cases. Eight aneurysms were successfully treated using one WEB SL without additional treatment. Three middle cerebral artery, four anterior communicating artery, and one basilar artery aneurysms were treated. Average dome width was 7.5 mm (range 5.4–10.7 mm), and average neck size was 4.9 mm (range 2.6–6.5 mm). No periprocedural complication was observed, and morbi-mortality at discharge and 6 months was 0.0%. Angiographic follow-up at 6 months demonstrated complete aneurysm occlusion in 2/8 aneurysms, neck remnant in 5/8 aneurysms, and aneurysm remnant in 1/8 aneurysm. Conclusions From this preliminary study, treatment of bifurcation intracranial aneurysms using WEB SL is feasible. WEB SL treatment seems safe at 6 months; however, the rate of neck remnants is not negligible due to compression of the WEB SL. Further technical improvements may be needed in order to ameliorate the occlusion in the WEB SL treatment. PMID:26111987

Computed Tomographic Distinction of Intimal and Medial Calcification in the Intracranial Internal Carotid Artery.

PubMed

Kockelkoren, Remko; Vos, Annelotte; Van Hecke, Wim; Vink, Aryan; Bleys, Ronald L A W; Verdoorn, Daphne; Mali, Willem P Th M; Hendrikse, Jeroen; Koek, Huiberdina L; de Jong, Pim A; De Vis, Jill B

2017-01-01

Intracranial internal carotid artery (iICA) calcification is associated with stroke and is often seen as a proxy of atherosclerosis of the intima. However, it was recently shown that these calcifications are predominantly located in the tunica media and internal elastic lamina (medial calcification). Intimal and medial calcifications are thought to have a different pathogenesis and clinical consequences and can only be distinguished through ex vivo histological analysis. Therefore, our aim was to develop CT scoring method to distinguish intimal and medial iICA calcification in vivo. First, in both iICAs of 16 cerebral autopsy patients the intimal and/or medial calcification area was histologically assessed (142 slides). Brain CT images of these patients were matched to the corresponding histological slides to develop a CT score that determines intimal or medial calcification dominance. Second, performance of the CT score was assessed in these 16 patients. Third, reproducibility was tested in a separate cohort. First, CT features of the score were circularity (absent, dot(s), <90°, 90-270° or 270-360°), thickness (absent, ≥1.5mm, or <1.5mm), and morphology (indistinguishable, irregular/patchy or continuous). A high sum of features represented medial and a lower sum intimal calcifications. Second, in the 16 patients the concordance between the CT score and the dominant calcification type was reasonable. Third, the score showed good reproducibility (kappa: 0.72 proportion of agreement: 0.82) between the categories intimal, medial or absent/indistinguishable. The developed CT score shows good reproducibility and can differentiate reasonably well between intimal and medial calcification dominance in the iICA, allowing for further (epidemiological) studies on iICA calcification.

Percutaneous endovascular therapy for symptomatic chronic total occlusion of the left subclavian artery.

PubMed

Akif Cakar, Mehmet; Tatli, Ersun; Tokatli, Alptug; Kilic, Harun; Gunduz, Huseyin; Akdemir, Ramazan

2018-03-16

Percutaneous endovascular therapy is an accepted and preferred procedure for symptomatic subclavian artery disease. However, the technical feasibility and effectiveness of treating chronic total occlusion of the subclavian artery with this approach is uncertain. We aimed to evaluate the initial and mid-term results of endovascular therapy for patients with symptomatic chronic total occlusion of the left subclavian artery. Consecutive patients who underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery between January 2010 and February 2014 were included. Overall, 16 patients (10 male, 6 female; mean age 56 ± 13 years) underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery - 6 (37.5%) had arm claudication, 8 (50.0%) had vertebrobasilar insufficiency and 2 (12.5%) had coronary steal. 18 balloon-expandable stents were implanted to 15 patients. The central luminal passage was not achieved in one patient because of the subintimal position of guidewire (procedural success rate 93.8%). There were no procedure-related complications. Mean preprocedural and postprocedural systolic blood pressure differences between the upper extremities were 37 ± 13 (range 25-60) mmHg and 11 ± 9 (range 5-38) mmHg, respectively; the improvement was statistically significant. Outpatient follow-up revealed one asymptomatic restenosis at two years. Patency rate at two years was 93.3%. Balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery is safe and effective, with good acute success rate and mid-term patency. Prospective randomised studies on larger patient populations would provide more precise results.

Posterior Communicating Artery Giving Rise to Shared-Origin Anterior Choroidal Artery: Case Illustration.

PubMed

Tonetti, Daniel A; Andrews, Edward G; Stabingas, Kristen; Tyler-Kabara, Elizabeth; Gross, Bradley A; Jadhav, Ashutosh

2018-01-01

The origin point of the anterior choroidal artery (AChA) is variable, typically arising from the supraclinoid internal carotid artery (ICA) distal to the posterior communicating artery (PComA) on either the posterolateral or posterior aspect of the ICA. Variations of AChA origin have important clinical implications, and rare origins reported previously include the ICA bifurcation and middle cerebral artery. We provide illustrations of a case of a shared-origin PComA and AChA. A young girl presented with intracranial hemorrhage and underwent angiography to evaluate for an underlying cause. Ultimately, 3-dimensional rotational angiography incidentally demonstrated a common origin of the AChA with the PComA. A rare case of a shared-origin AChA and PComA is reported for angiographic illustration. The radiologic findings, embryology behind the development of the AChA, and neurosurgical and neurovascular relevance of this variant are discussed. The importance of recognizing the origin of the AChA is emphasized. Copyright © 2017 Elsevier Inc. All rights reserved.

From Bench to Bedside: Utility of the Rabbit Elastase Aneurysm Model in Pre-Clinical Studies of Intracranial Aneurysm Treatment

PubMed Central

Brinjikji, Waleed; Ding, Yong H; Kallmes, David F; Kadirvel, Ramanathan

2016-01-01

Summary Pre-clinical studies are important in helping practitioners and device developers improve techniques and tools for endovascular treatment of intracranial aneurysms. Thus, an understanding of the major animal models used in such studies is important. The New Zealand rabbit elastase induced arterial aneurysm of the common carotid artery is one of the most commonly used models in testing the safety and efficacy of new endovascular devices. In this review we discuss 1) various techniques used to create the aneurysm, 2) complications of aneurysm creation, 3) natural history of the arterial aneurysm, 4) histopathologic and hemodynamic features of the aneurysm 5) devices tested using this model and 6) weaknesses of the model. We demonstrate how pre-clinical studies using this model are applied in treatment of intracranial aneurysms in humans. The model has a similar hemodynamic, morphological and histologic characteristics to human aneurysms and demonstrates similar healing responses to coiling as human aneurysms. Despite these strengths however, the model does have many weaknesses including the fact that the model does not emulate the complex inflammatory processes affecting growing and ruptured aneurysms. Furthermore the model’s extracranial location affects its ability to be used in preclinical safety assessments of new devices. We conclude that the rabbit elastase model has characteristics that make it a simple and effective model for preclinical studies on the endovascular treatment of intracranial aneurysms however further work is needed to develop aneurysm models that simulate the histopathologic and morphologic characteristics of growing and ruptured aneurysms. PMID:25904642

Temporal and Spatial Variances in Arterial Spin-Labeling Are Inversely Related to Large-Artery Blood Velocity.

PubMed

Robertson, A D; Matta, G; Basile, V S; Black, S E; Macgowan, C K; Detre, J A; MacIntosh, B J

2017-08-01

The relationship between extracranial large-artery characteristics and arterial spin-labeling MR imaging may influence the quality of arterial spin-labeling-CBF images for older adults with and without vascular pathology. We hypothesized that extracranial arterial blood velocity can explain between-person differences in arterial spin-labeling data systematically across clinical populations. We performed consecutive pseudocontinuous arterial spin-labeling and phase-contrast MR imaging on 82 individuals (20-88 years of age, 50% women), including healthy young adults, healthy older adults, and older adults with cerebral small vessel disease or chronic stroke infarcts. We examined associations between extracranial phase-contrast hemodynamics and intracranial arterial spin-labeling characteristics, which were defined by labeling efficiency, temporal signal-to-noise ratio, and spatial coefficient of variation. Large-artery blood velocity was inversely associated with labeling efficiency ( P = .007), temporal SNR ( P < .001), and spatial coefficient of variation ( P = .05) of arterial spin-labeling, after accounting for age, sex, and group. Correction for labeling efficiency on an individual basis led to additional group differences in GM-CBF compared to correction using a constant labeling efficiency. Between-subject arterial spin-labeling variance was partially explained by extracranial velocity but not cross-sectional area. Choosing arterial spin-labeling timing parameters with on-line knowledge of blood velocity may improve CBF quantification. © 2017 by American Journal of Neuroradiology.

Acute stroke with major intracranial vessel occlusion: Characteristics of cardioembolism and atherosclerosis-related in situ stenosis/occlusion.

PubMed

Horie, Nobutaka; Tateishi, Yohei; Morikawa, Minoru; Morofuji, Yoichi; Hayashi, Kentaro; Izumo, Tsuyoshi; Tsujino, Akira; Nagata, Izumi; Matsuo, Takayuki

2016-10-01

Acute ischemic stroke with major intracranial vessel occlusion is commonly due to cardioembolic or atherosclerosis-related in situ stenosis/occlusion, and immediate identification of these subtypes is important to establish the optimal treatment strategy. The aim of this study was to clarify the differences in clinical presentation, radiological findings, neurological temporal courses, and outcomes between these etiologies, which have not been fully evaluated. Consecutive emergency patients with acute ischemic stroke were retrospectively reviewed. Among them, patients with stroke with major intracranial vessel occlusion were analyzed with a focus on clinical and radiological findings, and a comparison was performed for those with cardioembolic or atherosclerosis-related in situ stenosis/occlusion. Of 1053 patients, 80 had stroke with acute major intracranial vessel occlusion (45 with cardioembolic and 35 with atherosclerosis-related in situ stenosis/occlusion). Interestingly, the susceptibility vessel sign (SVS) on T2-weighted MR angiography was more frequently detected in cardioembolic stroke (80.0%) than in atherosclerosis (in situ stenosis: 5.9%, chronic occlusion: 14.3%). Moreover, the proximal intra-arterial signal (IAS) on arterial spin labeling MRI and the distal IAS on fluid attenuated inversion recovery MRI was less frequently detected in chronic occlusion (27.3% and 50.0%, respectively) than in acute occlusion due to cardioembolic or in situ stenosis. Multivariate regression analysis showed that the SVS was significantly related to cardioembolism (adjusted odds ratio (OR): 21.68, P=0.004). Clinical characteristics of acute stroke with major intracranial vessel occlusion differ depending on the etiology. The SVS and proximal/distal IAS on MRI are useful to distinguish between cardioembolic and atherosclerotic-related in situ stenosis/occlusion. Copyright © 2016 Elsevier Ltd. All rights reserved.

Pontine infarction induced by injury of the perforating branch of the basilar artery after blunt head impact: case report.

PubMed

Yanagawa, Youichi; Iwamoto, Shin-ichiro; Nishi, Kouichirou

2008-08-01

A 77-year-old male pedestrian was hit by a car. On admission, he had disturbance of consciousness and left hemiplegia. Computed tomography (CT) indicated only left frontal subcutaneous hematoma and minor hemorrhage in the left frontal lobe, suggesting axonal injury. CT on hospital day 2 revealed a low density area in the right paramedian pons, but CT angiography showed no dissection or occlusion of the vertebrobasilar artery. The diagnosis was pontine infarction resulting from shearing force injury to the paramedian branch of the basilar artery. He was transferred to another hospital for rehabilitation without improvement of symptoms on hospital day 51. Paramedian pontine infarction tends to occur in patients with risk factors for arteriosclerosis, including hypertension, diabetes mellitus, hyperlipidemia, or smoking. The present elderly patient had hypertension and hyperlipidemia, so arteriosclerosis in the paramedian branch may have contributed to his susceptibility to such injury.

The anterior temporal artery: an underutilized but robust donor for revascularization of the distal middle cerebral artery.

PubMed

Tayebi Meybodi, Ali; Lawton, Michael T; Griswold, Dylan; Mokhtari, Pooneh; Payman, Andre; Benet, Arnau

2017-10-01

OBJECTIVE The anterior temporal artery (ATA) supplies an area of the brain that, if sacrificed, does not cause a noticeable loss of function. Therefore, the ATA may be used as a donor in intracranial-intracranial (IC-IC) bypass procedures. The capacities of the ATA as a donor have not been studied previously. In this study, the authors assessed the feasibility of using the ATA as a donor for revascularization of different segments of the distal middle cerebral artery (MCA). METHODS The ATA was studied in 15 cadaveric specimens (8 heads, excluding 1 side). First, the cisternal segment of the artery was untethered from arachnoid adhesions and small branches feeding the anterior temporal lobe and insular cortex, to evaluate its capacity for a side-to-side bypass to insular, opercular, and cortical segments of the MCA. Any branch entering the anterior perforated substance was preserved. Then, the ATA was cut at the opercular-cortical junction and the capacity for an end-to-side bypass was assessed. RESULTS From a total of 17 ATAs, 4 (23.5%) arose as an early MCA branch. The anterior insular zone and the frontal parasylvian cortical arteries were the best targets (in terms of mobility and caliber match) for a side-to-side bypass. Most of the insula was accessible for end-to-side bypass, but anterior zones of the insula were more accessible than posterior zones. End-to-side bypass was feasible for most recipient cortical arteries along the opercula, except for posterior temporal and parietal regions. Early ATAs reached significantly farther on the insular MCA recipients than non-early ATAs for both side-to-side and end-to-side bypasses. CONCLUSIONS The ATA is a robust arterial donor for IC-IC bypass procedures, including side-to-side and end-to-side techniques. The evidence provided in this work supports the use of the ATA as a donor for distal MCA revascularization in well-selected patients.

The Intracranial Volume Pressure Response in Increased Intracranial Pressure Patients: Clinical Significance of the Volume Pressure Indicator.

PubMed

Lai, Hung-Yi; Lee, Ching-Hsin; Lee, Ching-Yi

2016-01-01

For patients suffering from primary brain injury, monitoring intracranial pressure alone is not enough to reflect the dynamic intracranial condition. In our previous study, a segment of the pressure-volume curve can be expressed by the parabolic regression model with single indicator "a". The aim of this study is to evaluate if the indicator "a" can reflect intracranial conditions. Patients with traumatic brain injury, spontaneous intracranial hemorrhage, and/or hydrocephalus who had external ventricular drainage from January 2009 to February 2010 were included. The successive volume pressure response values were obtained by successive drainage of cerebral spinal fluid from intracranial pressure 20-25 mm Hg to 10 mm Hg. The relationship between withdrawn cerebral spinal fluid volume and intracranial pressure was analyzed by the parabolic regression model with single parameter "a". The overall mean for indicator "a" was 0.422 ± 0.046. The mean of "a" in hydrocephalus was 0.173 ± 0.024 and in severe intracranial mass with slender ventricle, it was 0.663 ± 0.062. The two extreme intracranial conditions had a statistical significant difference (p<0.001). The indicator "a" of a pressure-volume curve can reflect the dynamic intracranial condition and is comparable in different situations. A significantly larger indicator "a" with increased intracranial pressure is always observed in severe intracranial mass lesions with cerebral edema. A significantly smaller indicator "a" with increased intracranial pressure is observed in hydrocephalus. Brain computed tomography should be performed early if a rapid elevation of indicator "a" is detected, as it can reveal some ongoing intracranial pathology prior to clinical deterioration. Increased intracranial pressure was frequently observed in patients with intracranial pathology. The progression can be differentiated using the pattern of the volume pressure indicator.

The Intracranial Volume Pressure Response in Increased Intracranial Pressure Patients: Clinical Significance of the Volume Pressure Indicator

PubMed Central

2016-01-01

Background For patients suffering from primary brain injury, monitoring intracranial pressure alone is not enough to reflect the dynamic intracranial condition. In our previous study, a segment of the pressure-volume curve can be expressed by the parabolic regression model with single indicator “a”. The aim of this study is to evaluate if the indicator “a” can reflect intracranial conditions. Methods Patients with traumatic brain injury, spontaneous intracranial hemorrhage, and/or hydrocephalus who had external ventricular drainage from January 2009 to February 2010 were included. The successive volume pressure response values were obtained by successive drainage of cerebral spinal fluid from intracranial pressure 20–25 mm Hg to 10 mm Hg. The relationship between withdrawn cerebral spinal fluid volume and intracranial pressure was analyzed by the parabolic regression model with single parameter “a”. Results The overall mean for indicator “a” was 0.422 ± 0.046. The mean of “a” in hydrocephalus was 0.173 ± 0.024 and in severe intracranial mass with slender ventricle, it was 0.663 ± 0.062. The two extreme intracranial conditions had a statistical significant difference (p<0.001). Conclusion The indicator “a” of a pressure-volume curve can reflect the dynamic intracranial condition and is comparable in different situations. A significantly larger indicator “a” with increased intracranial pressure is always observed in severe intracranial mass lesions with cerebral edema. A significantly smaller indicator “a” with increased intracranial pressure is observed in hydrocephalus. Brain computed tomography should be performed early if a rapid elevation of indicator “a” is detected, as it can reveal some ongoing intracranial pathology prior to clinical deterioration. Increased intracranial pressure was frequently observed in patients with intracranial pathology. The progression can be differentiated using the pattern of the volume

Treatment of Recurrent Intracranial Aneurysms After Clipping: A Report of 23 Cases and a Review of the Literature.

PubMed

Hokari, Masaaki; Kazumara, Ken; Nakayama, Naoki; Ushikoshi, Satoshi; Sugiyama, Taku; Asaoka, Katsunori; Uchida, Kazuki; Shimbo, Daisuke; Itamoto, Koji; Yokoyama, Yuka; Isobe, Masanori; Imai, Tetsuaki; Osanai, Toshiya; Houkin, Kiyohiro

2016-08-01

There are no established treatment strategies for aneurysms that recur after clipping. In this study, we present cases of patients who experienced recurrent aneurysms after clipping and subsequently underwent surgical intervention. Between 2004 and 2015, we surgically treated 23 aneurysms that recurred at a previously clipped site. Patient characteristics and clinical history were retrospectively reviewed. Patients included 19 women and 4 men 45-81 years old. Aneurysms recurred 3-31 years (mean, 15.4 years) after the initial operation. For 18 cases, the first clinical presentation was a subarachnoid hemorrhage; aneurysms were incidentally diagnosed in 5 patients. Aneurysm locations were as follows: 9 on the internal carotid artery; 4 on the middle cerebral artery; 7 on the anterior communicating artery; 2 on the distal anterior cerebral artery; and 1 on the basilar artery. The reasons for retreatment included subarachnoid hemorrhage (n = 9) and aneurysm regrowth detected on follow-up examinations (n = 14). Endovascular treatment was performed in 10 cases, and direct surgery was performed in 13 cases (clipping in 8, clipping or trapping with bypass in 5). Various complex vascular reconstructions, including high-flow bypass and intracranial-intracranial in situ bypass, were performed for recurrent aneurysms. In our experience, coil embolization is a safe and effective procedure for treating recurrent aneurysms. When cases are unsuitable for coil embolization, surgical treatment often requires neurosurgeons not only to overcome the general technical difficulty of reoperative clipping but also to perform challenging vascular reconstruction. Copyright © 2016. Published by Elsevier Inc.

Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

MedlinePlus

... Asked Questions Español Condiciones Chinese Conditions Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) En Español Read in Chinese What is idiopathic intracranial hypertension? Idiopathic intracranial hypertension (IIH) is a disorder that ...

Prediction of intracranial hypertension through noninvasive intracranial pressure waveform analysis in pediatric hydrocephalus.

PubMed

Ballestero, Matheus Fernando Manzolli; Frigieri, Gustavo; Cabella, Brenno Caetano Troca; de Oliveira, Sergio Mascarenhas; de Oliveira, Ricardo Santos

2017-09-01

The purpose of this study is to evaluate a noninvasive device to assess intracranial pressure wave form in children with hydrocephalus. A prospective and non-experimental descriptive-analytic study was performed. Fifty-six patients were enrolled in this study. They were divided in four groups: group A, children with clinically compensated hydrocephalus; B, surgically treated hydrocephalus; C, patients with acute intracranial hypertension due to hydrocephalus; and D, children without neurological disease (control). Data were collected through the installation of an extracranial deformation sensor, coupled to the children's scalp, which allowed registration of noninvasive intracranial pressure curves. Parameters obtained were analyzed: P2/P1 ratio, "classification P1 and P2 and P1 slope. P2/P1 index and "classification of P1 and P2" had a sensitivity of 80% and specificity of 100% for predicting intracranial hypertension. "P1 slope" presented no statistical difference. This study showed a useful and noninvasive method for monitoring intracranial pressure, which was able to indicate the intracranial hypertension in children with hydrocephalus and, thus, should be further investigated for clinical applications.

Angiographic Features, Collaterals, and Infarct Topography of Symptomatic Occlusive Radiation Vasculopathy

PubMed Central

Zou, Winnie X.Y.; Leung, Thomas W.; Yu, Simon C.H.; Wong, Edward H.C.; Leung, S.F.; Soo, Yannie O.Y.; Ip, Vincent H.L.; Chan, Anne Y.Y.; Lam, Wynnie W.M.; Siu, Deyond Y.W.; Abrigo, Jill; Lee, Kwok Tung; Liebeskind, David S.; Wong, Ka Sing

2014-01-01

Background and Purpose Occlusive radiation vasculopathy (ORV) predisposes head-and-neck cancer survivors to ischemic strokes. Methods We analyzed the digital subtraction angiography acquired in 96 patients who had first-ever transient ischemic attack or ischemic strokes attributed to ORV. Another age-matched 115 patients who had no radiotherapy but symptomatic high-grade (>70%) carotid stenoses were enrolled as referent subjects. Digital subtraction angiography was performed within 2 months from stroke onset and delineated carotid and vertebrobasilar circulations from aortic arch up to intracranial branches. Two reviewers blinded to group assignment recorded all vascular lesions, collateral status, and infarct pattern. Results ORV patients had less atherosclerotic risk factors at presentation. In referent patients, high-grade stenoses were mostly focal at the proximal internal carotid artery. In contrast, high-grade ORV lesions diffusely involved the common carotid artery and internal carotid artery and were more frequently bilateral (54% versus 22%), tandem (23% versus 10%), associated with complete occlusion in one or both carotid arteries (30% versus 9%), vertebral artery (VA) steno-occlusions (28% versus 16%), and external carotid artery stenosis (19% versus 5%) (all P<0.05). With comparable rates of vascular anomaly, ORV patients showed more established collateral circulations through leptomeningeal arteries, anterior communicating artery, posterior communicating artery, suboccipital/costocervical artery, and retrograde flow in ophthalmic artery. In terms of infarct topography, the frequencies of cortical or subcortical watershed infarcts were similar in both groups. Conclusions ORV angiographic features and corresponding collaterals are distinct from atherosclerotic patterns at initial stroke presentation. Clinical decompensation, despite more extensive collateralization, may precipitate stroke in ORV. PMID:23306321

Anatomical Assessment of the Temporopolar Artery for Revascularization of Deep Recipients.

PubMed

Tayebi Meybodi, Ali; Benet, Arnau; Griswold, Dylan; Dones, Flavia; Preul, Mark C; Lawton, Michael T

2018-05-30

Intracranial-intracranial and extracranial-intracranial bypass options for revascularization of deep cerebral recipients are limited and technically demanding. To assess the anatomical feasibility of using the temporopolar artery (TPA) for revascularization of the anterior cerebral artery (ACA), posterior cerebral artery (PCA), and superior cerebellar arteries (SCA). Orbitozygomatic craniotomy was performed bilaterally on 8 cadaveric heads. The cisternal segment of the TPA was dissected. The TPA was cut at M3-M4 junction with its proximal and distal calibers and the length of the cisternal segment measured. Feasibility of the TPA-A1-ACA, TPA-A2-ACA, TPA-SCA, and TPA-PCA bypasses were assessed. A total of 17 TPAs were identified in 16 specimens. The average distal TPA caliber was 1.0 ± 0.2 mm, and the average cisternal length was 37.5 ± 9.4 mm. TPA caliber was ≥ 1.0 mm in 12 specimens (70%). The TPA-A1-ACA bypass was feasible in all specimens, whereas the TPA reached the A2-ACA, SCA, and PCA in 94% of specimens (16/17). At the point of anastomosis, the average recipient caliber was 2.5 ± 0.5 mm for A1-ACA, and 2.3 ± 0.7 mm for A2-ACA. The calibers of the SCA and PCA at the anastomosis points were 2.0 ± 0.6 mm, and 2.7 ± 0.8 mm, respectively. The TPA-ACA, TPA-PCA, and TPA-SCA bypasses are anatomically feasible and may be used when the distal caliber of the TPA stump is optimal to provide adequate blood flow. This study lays foundations for clinical use of the TPA for ACA revascularization in well-selected cases.

What Is IH (Intracranial Hypertension)?

MedlinePlus

... the body cannot effectively absorb or drain CSF, intracranial pressure increases within the skull, which is made of ... the vasculature can only be compressed so far, intracranial pressure must rise. Intracranial hypertension in adults is generally ...

Measuring Hemodynamic Changes in the Ophthalmic Artery During Applied Force for Noninvasive Intracranial Pressure Monitoring: Test Results in a Porcine Model.

PubMed

Twedt, Max; Pfeifer, Chase; Thorell, William; Bashford, Greg

2017-03-01

Possible traumatic brain injury victims would greatly benefit from a handheld, noninvasive intracranial pressure (ICP) monitoring tool, which a medic could operate in a remote area. Such a device would also benefit the transport of injured soldiers during en route medical care and critical care air transport. This study demonstrates the use of noninvasive blood flow measurements in the eye by ultrasound as a proxy for ICP. ICP was artificially raised in a porcine model and resultant blood flow change in the ophthalmic artery was measured. In addition, the ultrasound transducer itself was used to compress the eye further altering ophthalmic hemodynamics. Blood flow velocities at a range of applied forces and ICP were compared. It was found that 3.25 N of force applied to the cornea was sufficient to produce significant changes in ophthalmic artery blood dynamics regardless of the ICP value. Specifically, the change in resistivity index (RI) and pulsatility index (PI) as force was applied to the cornea correlated with ICP levels. In multiple animal experiments, the magnitude of PI/RI percent change was inversely related to differences in ICP. Force applied to the cornea at baseline ICP resulted in a 15% increase in PI/RI. Results indicate that as ICP increases, the percent change in PI/RI while force is applied decreases. The consistency of data collected indicates that a trend line developed with this data and from similar experiments could be used as a predictive measurement of ICP. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

Multiple encephalogaleoperiosteal synangiosis for bilateral carotid artery stenosis in a 13-year-old girl: a case report.

PubMed

Inamura, Akinori; Nomura, Sadahiro; Sadahiro, Hirokazu; Oku, Takayuki; Ishihara, Hideyuki; Suzuki, Michiyasu

2016-05-01

Encephalogaleoperiosteal synangiosis (EGS) has been widely used to treat children with moyamoya disease (MMD). We present the first case of successful multiple EGS in a patient with brain ischemic disease who presented with different cerebrovascular findings from MMD. A 13-year-old girl had an increased frequency of transient ischemic attacks that affected her right extremities. Digital subtraction angiography showed tapering of the internal carotid artery (ICA). The anterior cerebral artery (ACA) and middle cerebral artery (MCA) were visible on vertebral angiogram, but not on carotid angiogram. The intact circle of Willis and lack of hypervascularity of the lenticulostriate arteries were observed. Decreased regional cerebral blood flow (CBF) in the bilateral ACA and MCA territories quantified by (123)I-N-isopropyl-p-iodoamphetamine-single photon emission computed tomography indicated the need for extracranial-intracranial bypass surgery. Multiple EGS procedures were performed instead of direct anastomosis, which is the standard procedure for intracranial ICA stenosis, because the space for the craniotomy was limited by transdural anastomosis. Despite the fact that the diagnosis of MMD was questionable, the hemispheres were well vascularized, and the neurology and CBF improved postoperatively. The preserved circle of Willis and lack of moyamoya vessels were inconsistent with the features of MMD. However, childhood onset, bilateralness, chronic intracranial ICA stenosis, and transdural anastomosis indicated the same underling pathogenicity as MMD. It is hypothesized that ICA stenosis occurred immediately proximal to the posterior communicating artery in this case. This would have produced the atypical finding of the remaining circle of Willis without growth of the basal moyamoya vessels.

Comparison of isoflurane and propofol for maintenance of anesthesia in dogs with intracranial disease undergoing magnetic resonance imaging.

PubMed

Caines, Deanne; Sinclair, Melissa; Valverde, Alexander; Dyson, Doris; Gaitero, Luis; Wood, Darren

2014-09-01

To compare isoflurane and propofol for maintenance of anesthesia and quality of recovery in client-owned dogs with intracranial disease undergoing magnetic resonance imaging (MRI). Prospective, randomized, clinical trial. Twenty-five client-owned dogs with intracranial pathology, 13 females and 12 males, ages 11 months to 13 years, weighing between 3.0 and 48.0 kg. Each dog was randomly assigned to receive propofol or isoflurane for maintenance of anesthesia. All dogs were not premedicated, were administered propofol intravenously to effect for induction, intubated and mechanically ventilated to maintain an end-tidal carbon dioxide tension 30-35 mmHg (4.0-4.7 kPa). Temperature and cardiac output were measured pre- and post-MRI. Scores for mentation, neurological status, ease of maintenance, and recovery were obtained pre- and post-anesthesia. Pulse oximetry, end-tidal gases, arterial blood pressure, heart rate (HR) and requirements for dopamine administration to maintain mean arterial pressure (MAP) >60 mmHg were recorded throughout anesthesia. End-tidal isoflurane concentration was 0.73 ± 0.35% and propofol infusion rate was 292 ± 119 μg kg(-1)  minute(-1) . Cardiac index was higher, while HR was lower, with propofol than isoflurane in dogs younger than 5 years, but not in older dogs. Dogs maintained with isoflurane were 14.7 times more likely to require dopamine than propofol dogs. Mentation and maintenance scores and temperature were not different. MAP and diastolic arterial pressure were higher in the propofol group. Recovery scores were better with propofol, although times to extubation were similar. Change in neurological score from pre- to post-anesthesia was not different between treatments. Dogs maintained with propofol during MRI had higher arterial pressures, decreased requirements for dopamine, and better recovery scores, compared to dogs maintained with isoflurane. Propofol anesthesia offered cardiovascular and recovery advantages over

Anatomical Variability in the Termination of the Basilar Artery in the Human Cadaveric Brain.

PubMed

Gunnal, Sandhya; Farooqui, Mujeebuddin; Wabale, Rajendra

2015-01-01

The basilar artery (BA) is the prominent median vessel of the vertebrobasilar circulation and usually terminates into two posterior cerebral arteries forming the posterior angle of the Circle of Willis (CW). To tackle different variations of CW, basilar artery acts as a guideline for neuroradiologists and neurosurgeons. Basilar termination is the most frequent site of aneurysm. Abnormalities at the site of termination may compress the oculomotor nerve. Variations at the termination may complicate surgeries at the base of brain. The present study aims to add to the knowledge regarding the termination pattern of the BA. 170 BA terminations were studied. Morphological variations in the termination pattern were noted. Frequency of variations in termination patterns was recorded. Dimensions of BA were measured. Data were analyzed. Morphological variations in termination were seen in 17.64%. Bifurcation, Trifurcation, Quadrifurcation, Pentafurcation and Nonfurcation of BA was seen in 82.35%, 5.29%, 5.88%, 3.52% and 2.94% respectively. BA associated with aneurysm and Fenestration was seen in 3.52% and 1.17% respectively. Mean length and diameter of BA was 30.27 mm and 4.8 mm respectively. Awareness of these anatomical variations in termination patterns of BA is important in neurovascular procedures.

Anomalous origins of bilateral vertebral arteries in a child with Down syndrome and Moyamoya disease. A case report.

PubMed

Mishra, A; Pendharkar, H; Jayadaevan, E R; Bodhey, N

2012-09-01

Variations in vertebral artery origin and course are well-described in the literature. The origin of right vertebral artery from the right common carotid artery is an extremely rare variant. We describe a unique case of a child with Down syndrome with variant origins of bilateral vertebral artery, an aberrant right subclavian artery and concomitant Moyamoya disease of intracranial circulation. The presence of variations of the origin and course of craniocervical arteries might have profound implications in angiographic and surgical procedures and hence it is of great importance to be aware of such a possibility.

Intracranial atherosclerosis: current concepts.

PubMed

Arenillas, Juan F

2011-01-01

The most relevant ideas discussed in this article are described here. Intracranial atherosclerotic disease (ICAD) represents the most common cause of ischemic stroke worldwide. Its importance in whites may have been underestimated. New technical developments, such as high-resolution MRI, allow direct assessment of the intracranial atherosclerotic plaque, which may have a profound impact on ICAD diagnosis and therapy in the near future. Early detection of ICAD may allow therapeutic intervention while the disease is still asymptomatic. The Barcelonès Nord and Maresme Asymptomatic Intracranial Atherosclerosis Study is presented here. The main prognostic factors that characterize the patients who are at a higher risk for ICAD recurrence are classified and discussed. The best treatment for ICAD remains to be established. The Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Study is currently ongoing to address this crucial issue. These and other topics will be discussed at the Fifth International Intracranial Atherosclerosis Conference (Valladolid, Spain, autumn 2011).

Primary stenting of subclavian and innominate artery occlusive disease: a single center's experience.

PubMed

Brountzos, E N; Petersen, B; Binkert, C; Panagiotou, I; Kaufman, J A

2004-01-01

To review immediate and midterm results of primary stenting for innominate and subclavian artery occlusive lesions. Retrospective data were collected from 48 consecutive symptomatic patients (27 men and 21 women, median age 64 years) having 49 subclavian and innominate artery lesions treated with stenting. Of the patients 52% had concomitant ischemic heart disease, and 30% had carotid and/or vertebral artery disease. Indication for treatment was vertebrobasilar insufficiency (VBI) in 16.6% of the patients; upper limb ischemia (ULI) in 31.3%; VBI and ULI in 12.5%; transient ischemic attack in 16.7%; angina in 12.5% before or after left internal mammary artery-to-coronary artery bypass grafting; and leg claudication in 10.4% before or after axillofemoral bypass grafting. Balloon-expandable stents were used in 44 lesions and self-expandable stents in 5 lesions. In total, 53 stents were placed in 48 patients. Technical success was 96%, and clinical success 94%. We encountered four complications (two puncture site hematomas, one distal hand embolization and one transient cerebral ischemia). Two patients died within 30 days from other causes, and seven patients were lost to follow-up. Mean follow-up time was 16.7 months (range 0.3 to 68.2). Five patients had recurrent lesions treated by surgical (n = 2) or endovascular (n = 3) means. Cumulative primary patency rate was 91.7% and 77% at 12 and 24 months, respectively. Cumulative secondary patency rate was 96.5% and 91.7% at 12 and 24 months, respectively. Stenting of subclavian and innominate artery lesions resulted in immediate resolution of patients' symptoms with durable midterm effect and few complications in a larger patient group with serious comorbid conditions.

Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure

PubMed Central

2016-01-01

For 200 years, the ‘closed box’ analogy of intracranial pressure (ICP) has underpinned neurosurgery and neuro-critical care. Cushing conceptualised the Monro-Kellie doctrine stating that a change in blood, brain or CSF volume resulted in reciprocal changes in one or both of the other two. When not possible, attempts to increase a volume further increase ICP. On this doctrine’s “truth or relative untruth” depends many of the critical procedures in the surgery of the central nervous system. However, each volume component may not deserve the equal weighting this static concept implies. The slow production of CSF (0.35 ml/min) is dwarfed by the dynamic blood in and outflow (∼700 ml/min). Neuro-critical care practice focusing on arterial and ICP regulation has been questioned. Failure of venous efferent flow to precisely match arterial afferent flow will yield immediate and dramatic changes in intracranial blood volume and pressure. Interpreting ICP without interrogating its core drivers may be misleading. Multiple clinical conditions and the cerebral effects of altitude and microgravity relate to imbalances in this dynamic rather than ICP per se. This article reviews the Monro-Kellie doctrine, categorises venous outflow limitation conditions, relates physiological mechanisms to clinical conditions and suggests specific management options. PMID:27174995

Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure.

PubMed

Wilson, Mark H

2016-08-01

For 200 years, the 'closed box' analogy of intracranial pressure (ICP) has underpinned neurosurgery and neuro-critical care. Cushing conceptualised the Monro-Kellie doctrine stating that a change in blood, brain or CSF volume resulted in reciprocal changes in one or both of the other two. When not possible, attempts to increase a volume further increase ICP. On this doctrine's "truth or relative untruth" depends many of the critical procedures in the surgery of the central nervous system. However, each volume component may not deserve the equal weighting this static concept implies. The slow production of CSF (0.35 ml/min) is dwarfed by the dynamic blood in and outflow (∼700 ml/min). Neuro-critical care practice focusing on arterial and ICP regulation has been questioned. Failure of venous efferent flow to precisely match arterial afferent flow will yield immediate and dramatic changes in intracranial blood volume and pressure. Interpreting ICP without interrogating its core drivers may be misleading. Multiple clinical conditions and the cerebral effects of altitude and microgravity relate to imbalances in this dynamic rather than ICP per se. This article reviews the Monro-Kellie doctrine, categorises venous outflow limitation conditions, relates physiological mechanisms to clinical conditions and suggests specific management options. © The Author(s) 2016.

Stenting for symptomatic vertebral artery stenosis: The Vertebral Artery Ischaemia Stenting Trial.

PubMed

Markus, Hugh S; Larsson, Susanna C; Kuker, Wilhelm; Schulz, Ursula G; Ford, Ian; Rothwell, Peter M; Clifton, Andrew

2017-09-19

To compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis. VIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant. Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1-4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14-1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 ( p = 0.05). Stenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk. ISRCTN95212240. This study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting. Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

MRI Evidence for Altered Venous Drainage and Intracranial Compliance in Mild Traumatic Brain Injury

PubMed Central

Pomschar, Andreas; Koerte, Inga; Lee, Sang; Laubender, Ruediger P.; Straube, Andreas; Heinen, Florian; Ertl-Wagner, Birgit; Alperin, Noam

2013-01-01

Purpose To compare venous drainage patterns and associated intracranial hydrodynamics between subjects who experienced mild traumatic brain injury (mTBI) and age- and gender-matched controls. Methods Thirty adult subjects (15 with mTBI and 15 age- and gender-matched controls) were investigated using a 3T MR scanner. Time since trauma was 0.5 to 29 years (mean 11.4 years). A 2D-time-of-flight MR-venography of the upper neck was performed to visualize the cervical venous vasculature. Cerebral venous drainage through primary and secondary channels, and intracranial compliance index and pressure were derived using cine-phase contrast imaging of the cerebral arterial inflow, venous outflow, and the craniospinal CSF flow. The intracranial compliance index is the defined as the ratio of maximal intracranial volume and pressure changes during the cardiac cycle. MR estimated ICP was then obtained through the inverse relationship between compliance and ICP. Results Compared to the controls, subjects with mTBI demonstrated a significantly smaller percentage of venous outflow through internal jugular veins (60.9±21% vs. controls: 76.8±10%; p = 0.01) compensated by an increased drainage through secondary veins (12.3±10.9% vs. 5.5±3.3%; p<0.03). Mean intracranial compliance index was significantly lower in the mTBI cohort (5.8±1.4 vs. controls 8.4±1.9; p<0.0007). Consequently, MR estimate of intracranial pressure was significantly higher in the mTBI cohort (12.5±2.9 mmHg vs. 8.8±2.0 mmHg; p<0.0007). Conclusions mTBI is associated with increased venous drainage through secondary pathways. This reflects higher outflow impedance, which may explain the finding of reduced intracranial compliance. These results suggest that hemodynamic and hydrodynamic changes following mTBI persist even in the absence of clinical symptoms and abnormal findings in conventional MR imaging. PMID:23405151

Changes in blood flow due to stented parent artery expansion in an intracranial aneurysm.

PubMed

Mori, Futoshi; Ohta, Makoto; Matsuzawa, Teruo

2015-01-01

Stent placement is thought to obstruct the inflow of blood to an aneurysm. However, we introduced parent artery expansion and demonstrated that this may reduce the blood flow by the stent. In our previous study using idealized shapes, the results showed that flow reduction was greater than 22.2%, even if the expansion rate was only 6%. Furthermore, the parent artery expansion is predominantly caused by the effect of flow reduction as compared to that of flow reduction due to the obstruction of flow under stent placement. However, a realistic shape is complex and the blood flow also becomes complex flow. It is not understood whether the results of flow in the idealized shape are reflective of flow from a realistic 3D model. Therefore, we examined the effect of parent artery expansion using a realistic model. The aim is to clarify the effects of parent artery expansion on inflow rate, wall shear stress, and oscillatory shear index. We used a patient-specific geometry of a human internal carotid artery with an aneurysm. The geometry of parent artery expansion due to oversized stent constructed based on the voronoi diagram. We performed calculations in the unsteady-state situations using constructed models. The complexity of the flow in the aneurysm decreases in case of expanded parent artery. The inflow rate decreases by 33.6% immediately after parent artery expansion alone without a stent. The effect of the parent artery expansion on flow reduction is larger than that of the obstruction flow by stent placement. In addition, wall shear stress and oscillatory shear index on the aneurysm wall decrease by change in blood flow due to the parent artery expansion. The effects of the parent artery expansion in a realistic aneurysm model with different stent lengths were evaluated on the basis of a numerical simulation. Although the flow was complex, the parent artery expansion with stent reduces the inflow to the aneurysm and wall shear stress and oscillatory shear index on

Efficacy and Safety of Continuous Micro-Pump Infusion of 3% Hypertonic Saline combined with Furosemide to Control Elevated Intracranial Pressure.

PubMed

Li, Yuqian; Li, Zhihong; Li, Min; Yang, Yanlong; Wang, Bao; Gao, Li; Zhang, Xingye; Cheng, Hongyu; Fang, Wei; Zhao, Bo; Wang, Boliang; Gao, Guodong; Li, Lihong

2015-06-17

Elevated intracranial pressure is one of the most common problems in patients with diverse intracranial disorders, leading to increased morbidity and mortality. Effective management for increased intracranial pressure is based mainly on surgical and medical techniques with hyperosmolar therapy as one of the core medical treatments. The study aimed to explore the effects of continuous micro-pump infusions of 3% hypertonic saline combined with furosemide on intracranial pressure control. We analyzed data on 56 eligible participants with intracranial pressure >20 mmHg from March 2013 to July 2014. The target was to increase and maintain plasma sodium to a level between 145 and 155 mmol/L and osmolarity to a level of 310 to 320 mOsmol/kg. Plasma sodium levels significantly increased from 138±5 mmol/L at admission to 151±3 mmol/L at 24 h (P<0.01). Osmolarity increased from 282±11 mOsmol/kg at baseline to 311±8 mOsmol/kg at 24 h (P<0.01). Intracranial pressure significantly decreased from 32±7 mmHg to 15±6 mmHg at 24 h (P<0.01). There was a significant improvement in CPP (P<0.01). Moreover, central venous pressure, mean arterial pressure, and Glasgow Coma Scale slightly increased. However, these changes were not statistically significant. Continuous infusion of 3% hypertonic saline + furosemide is effective and safe for intracranial pressure control.

Intracranial pressure and cerebral perfusion pressure in patients developing brain death.

PubMed

Salih, Farid; Holtkamp, Martin; Brandt, Stephan A; Hoffmann, Olaf; Masuhr, Florian; Schreiber, Stephan; Weissinger, Florian; Vajkoczy, Peter; Wolf, Stefan

2016-08-01

We investigated whether a critical rise of intracranial pressure (ICP) leading to a loss of cerebral perfusion pressure (CPP) could serve as a surrogate marker of brain death (BD). We retrospectively analyzed ICP and CPP of patients in whom BD was diagnosed (n = 32, 16-79 years). Intracranial pressure and CPP were recorded using parenchymal (n = 27) and ventricular probes (n = 5). Data were analyzed from admission until BD was diagnosed. Intracranial pressure was severely elevated (mean ± SD, 95.5 ± 9.8 mm Hg) in all patients when BD was diagnosed. In 28 patients, CPP was negative at the time of diagnosis (-8.2 ± 6.5 mm Hg). In 4 patients (12.5%), CPP was reduced but not negative. In these patients, minimal CPP was 4 to 18 mm Hg. In 1 patient, loss of CPP occurred 4 hours before apnea completed the BD syndrome. Brain death was universally preceded by a severe reduction of CPP, supporting loss of cerebral perfusion as a critical step in BD development. Our data show that a negative CPP is neither sufficient nor a prerequisite to diagnose BD. In BD cases with positive CPP, we speculate that arterial blood pressure dropped below a critical closing pressure, thereby causing cessation of cerebral blood flow. Copyright © 2016 Elsevier Inc. All rights reserved.

Racial differences in vascular risk factors and outcomes of patients with intracranial atherosclerotic arterial stenosis.

PubMed

Waddy, Salina P; Cotsonis, George; Lynn, Michael J; Frankel, Michael R; Chaturvedi, Seemant; Williams, Janice E; Chimowitz, Marc

2009-03-01

Atherosclerotic intracranial stenosis is an important cause of stroke in blacks, yet there are limited data on vascular risk factors and outcome. We analyzed the vascular risk factors and outcomes of blacks and whites in the Warfarin versus Aspirin for Symptomatic Intracranial Disease (WASID) trial. Baseline characteristics and outcomes (ischemic stroke, brain hemorrhage, or vascular death combined and ischemic stroke alone) were compared between blacks (n=174) and whites (n=331) using univariate and multivariate analyses. Blacks were significantly (P<0.05) more likely than whites to be/have: female, hypertension history, diabetes history, higher LDL, higher total cholesterol, lower triglycerides, unmarried, unemployed, nonprivate insurance, no insurance, stroke as qualifying event, <70% stenosis, symptomatic anterior circulation vessel, no antithrombotic medication before qualifying event, and no family history of myocardial infarction. Blacks more frequently reached an end point of ischemic stroke, brain hemorrhage or vascular death (28% versus 20%; hazard ratio of 1.49, 95% CI 1.03 to 2.17, P=0.03), had a higher 2-year event rate (0.28 versus 0.19), and reached the end point of ischemic stroke alone (25% versus 16% at 2 years; hazard ratio of 1.62, P=0.017). In multivariate analysis, race was associated with ischemic stroke (P=0.0488) but not with the end point ischemic stroke, brain hemorrhage or vascular death (P=0.188). Blacks with intracranial stenosis are at higher risk of stroke recurrence than whites. This risk warrants additional study of factors contributing to stroke in blacks and highlights the need for aggressive risk factor management in blacks to prevent recurrence.

Parameter Optimization for Selected Correlation Analysis of Intracranial Pathophysiology.

PubMed

Faltermeier, Rupert; Proescholdt, Martin A; Bele, Sylvia; Brawanski, Alexander

2015-01-01

Recently we proposed a mathematical tool set, called selected correlation analysis, that reliably detects positive and negative correlations between arterial blood pressure (ABP) and intracranial pressure (ICP). Such correlations are associated with severe impairment of the cerebral autoregulation and intracranial compliance, as predicted by a mathematical model. The time resolved selected correlation analysis is based on a windowing technique combined with Fourier-based coherence calculations and therefore depends on several parameters. For real time application of this method at an ICU it is inevitable to adjust this mathematical tool for high sensitivity and distinct reliability. In this study, we will introduce a method to optimize the parameters of the selected correlation analysis by correlating an index, called selected correlation positive (SCP), with the outcome of the patients represented by the Glasgow Outcome Scale (GOS). For that purpose, the data of twenty-five patients were used to calculate the SCP value for each patient and multitude of feasible parameter sets of the selected correlation analysis. It could be shown that an optimized set of parameters is able to improve the sensitivity of the method by a factor greater than four in comparison to our first analyses.

Parameter Optimization for Selected Correlation Analysis of Intracranial Pathophysiology

PubMed Central

Faltermeier, Rupert; Proescholdt, Martin A.; Bele, Sylvia; Brawanski, Alexander

2015-01-01

Recently we proposed a mathematical tool set, called selected correlation analysis, that reliably detects positive and negative correlations between arterial blood pressure (ABP) and intracranial pressure (ICP). Such correlations are associated with severe impairment of the cerebral autoregulation and intracranial compliance, as predicted by a mathematical model. The time resolved selected correlation analysis is based on a windowing technique combined with Fourier-based coherence calculations and therefore depends on several parameters. For real time application of this method at an ICU it is inevitable to adjust this mathematical tool for high sensitivity and distinct reliability. In this study, we will introduce a method to optimize the parameters of the selected correlation analysis by correlating an index, called selected correlation positive (SCP), with the outcome of the patients represented by the Glasgow Outcome Scale (GOS). For that purpose, the data of twenty-five patients were used to calculate the SCP value for each patient and multitude of feasible parameter sets of the selected correlation analysis. It could be shown that an optimized set of parameters is able to improve the sensitivity of the method by a factor greater than four in comparison to our first analyses. PMID:26693250

Imaging of Intracranial Pressure Disorders.

PubMed

Holbrook, John; Saindane, Amit M

2017-03-01

Intracranial pressure (ICP) is the pressure inside the bony calvarium and can be affected by a variety of processes, such as intracranial masses and edema, obstruction or leakage of cerebrospinal fluid, and obstruction of venous outflow. This review focuses on the imaging of 2 important but less well understood ICP disorders: idiopathic intracranial hypertension and spontaneous intracranial hypotension. Both of these ICP disorders have salient imaging findings that are important to recognize to help prevent their misdiagnosis from other common neurological disorders. Copyright © 2017 by the Congress of Neurological Surgeons.

Intracranial distribution of the sympathetic system in mice: DiI tracing and immunocytochemical labeling

NASA Technical Reports Server (NTRS)

Maklad, A.; Quinn, T.; Fritzsch, B.

2001-01-01

The intracranial distribution of the cephalic branches of the superior cervical ganglion (scg) was studied in mice using indocarbocyanine dye (DiI) anterograde tracing. Two main branches were traced from the scg. The first branch joined the nerve of the pterygoid canal (the vidian nerve), npc, from which several intracranial sympathetic branches passed to the branches of the trigeminal nerve (tgn), abducent nerve (abn), trochlear nerve (trn), and oculomotor nerve (ocn). Most of the second branch joined the abn, from which sympathetic fibers dispersed in the distal region of the trigeminal ganglion (tgg) to form a plexus close to the ganglion's branches. Branches from this plexus joined the branches of the tgn, trn, and ocn. Several minor branches arising from the second branch of the scg were also observed. One formed a sympathetic plexus around the internal carotid artery (ica); a second formed a sympathetic plexus in the proximal region of tgg, close to its root; and a third branch coursed laterally to reach the ear by passing along the greater petrosal nerve (gpn). All of the intracranial trajectories traced from scg were found to be catecholaminergic, and likely sympathetic, using tyrosine hydroxylase (TH) immunocytochemistry.

Intracranial vessel wall imaging for evaluation of steno-occlusive diseases and intracranial aneurysms.

PubMed

Brinjikji, Waleed; Mossa-Basha, Mahmud; Huston, John; Rabinstein, Alejandro A; Lanzino, Giuseppe; Lehman, Vance T

2017-03-01

Cerebrovascular diseases have traditionally been classified, diagnosed and managed based on their luminal characteristics. However, over the past several years, several advancements in MRI techniques have ushered in high-resolution vessel wall imaging (HR-VWI), enabling evaluation of intracranial vessel wall pathology. These advancements now allow us to differentiate diseases which have a common angiographic appearance but vastly different natural histories (i.e. moyamoya versus atherosclerosis, reversible cerebral vasoconstriction syndrome versus vasculitis, stable versus unstable intracranial aneurysms). In this review, we detail the anatomical, histopathological and imaging characteristics of various intracranial steno-occlusive diseases and types of intracranial aneurysms and describe the role that HR-VWI can play in diagnosis, risk stratification and treatment. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Intracranial hypertension: classification and patterns of evolution

PubMed Central

Iencean, SM

2008-01-01

Intracranial hypertension (ICH) was systematized in four categories according to its aetiology and pathogenic mechanisms: parenchymatous ICH with an intrinsic cerebral cause; vascular ICH, which has its aetiology in disorders of cerebral blood circulation; ICH caused by disorders of cerebro–spinal fluid dynamics and idiopathic ICH. The increase of intracranial pressure is the first to happen and then intracranial hypertension develops from this initial effect becoming symptomatic; it then acquires its individuality, surpassing the initial disease. The intracranial hypertension syndrome corresponds to the stage at which the increased intracranial pressure can be compensated and the acute form of intracranial hypertension is equivalent to a decompensated ICH syndrome. The decompensation of intracranial hypertension is a condition of instability and appears when the normal intrinsic ratio of intracranial pressure – time fluctuation is changed. The essential conditions for decompensation of intracranial hypertension are: the speed of intracranial pressure increase over normal values, the highest value of abnormal intracranial pressure and the duration of high ICP values. Medical objectives are preventing ICP from exceeding 20 mm Hg and maintaining a normal cerebral blood flow. The emergency therapy is the same for the acute form but each of the four forms of ICH has a specific therapy, according to the pathogenic mechanism and if possible to aetiology. PMID:20108456

Electrophysiological monitoring during basilar aneurysm operation.

PubMed

Little, J R; Lesser, R P; Luders, H

1987-03-01

Intraoperative brain stem auditory evoked potential (BAEP) and somatosensory evoked potential (SEP) monitoring was evaluated in 16 patients each undergoing intracranial operation for basilar artery aneurysm. The 16 patients had 18 posterior circulation aneurysms, including 2 patients with 2 aneurysms. Fourteen aneurysms arose from the rostral basilar artery, 2 arose from the midbasilar artery, 1 arose from the vertebrobasilar junction, and 1 arose from the proximal segment of the posterior cerebral artery. Five aneurysms were classified as giant (i.e., greater than 25 mm), and 5 aneurysms were large (i.e., 15 to 25 mm). Ten patients had BAEP and SEP monitoring, 4 had BAEP monitoring only, and 2 had SEP monitoring only. Two patients showed significant abnormalities during operation, including 1 patient with transient changes in the BAEP when the lower pons and the 8th cranial nerve were retracted. Another patient had progressive increases in latency and decreases in amplitude and subsequent loss of the SEP cortical components during a period of intermittent temporary rostral basilar artery occlusion. Wave P13 was also lost during that period. The cortical components as well as Wave P13 returned after circulation was restored. The BAEPs were unchanged in the same patient during the period of temporary basilar artery occlusion. Fourteen patients had no significant abnormalities. There were no consistent changes during the various stages of operation. BAEP and SEP monitoring failed to identify ischemic events in 4 patients with neurological findings of brain stem ischemia immediately after operation (i.e., 25% false-negative studies).(ABSTRACT TRUNCATED AT 250 WORDS)

Successful flow reduction surgery for a ruptured true posterior communicating artery aneurysm caused by the common carotid artery ligation for epistaxis.

PubMed

Yamao, Yukihiro; Takahashi, Jun C; Satow, Tetsu; Iihara, Koji; Miyamoto, Susumu

2014-01-01

Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging. The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery. M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators.

Intracranial atherosclerosis is associated with progression of neurological deficit in subcortical stroke.

PubMed

Hallevi, Hen; Chernyshev, Oleg Y; El Khoury, Ramy; Soileau, Michael J; Walker, Kyle C; Grotta, James C; Savitz, Sean I

2012-01-01

Progression of neurological deficit (PND) is a frequent complication of acute subcortical ischemic stroke (SCS). The role of intracranial atherosclerosis (IAS) in PND is controversial. Our goal was to evaluate IAS on admission, as predictor of PND in SCS patients. SCS patients were identified from our prospective database from 2004 to 2008. Clinical and laboratory data were collected from charts, and radiographic data from original radiographs. The proximal intracranial arteries were graded as patent, irregular, stenotic, or occlusion. IAS was defined as irregularity or stenosis. PND was defined as a change in the National Institutes of Health Stroke Scale >1 point. Two hundred and two SCS patients were identified. In 14%, PND occurred at a median of 2 days from onset. Univariate analysis by infarct location showed the following to be associated with PND: for anterior circulation infarcts (centrum semiovale/basal ganglia), M1 atherosclerosis (p = 0.042); for posterior circulation infarcts, vertebral artery atherosclerosis (p = 0.018). For both groups, we found a non-significant association with age (p = 0.2) and HbA1c levels (p = 0.095). No association was found with admission glucose levels. Multivariate analysis showed the following association with PND: for anterior circulation infarcts, M1 atherosclerosis (OR 4.7; 95% CI 1.2-18.8; p = 0.03); for pontine infarcts, vertebral artery atherosclerosis (OR 5.8; 95% CI 1.1-29.4; p = 0.033). There was an increase in PND likelihood with an increasing number of atherosclerotic vessels. In our cohort of SCS patients, PND was associated with IAS of the responsible vessels. These results suggest a role for IAS in the pathogenesis of PNF in SCS patients. Copyright © 2011 S. Karger AG, Basel.

Posterior communicating and vertebral artery configuration and outcome in endovascular treatment of acute basilar artery occlusion.

PubMed

Haussen, Diogo C; Dharmadhikari, Sushrut S; Snelling, Brian; Lioutas, Vasileios-Arsenios; Thomas, Ajith; Peterson, Eric C; Elhammady, Mohamed Samy; Aziz-Sultan, Mohammad Ali; Yavagal, Dileep R

2015-12-01

We aimed to evaluate if vertebrobasilar anatomic variations impact reperfusion and outcome in intra-arterial therapy (IAT) for basilar artery occlusion (BAO). Consecutive BAO patients with symptom onset <24 h treated with IAT were included. Vertebral artery (VA) V3 and posterior communicating artery (PCoA) diameters were measured (CT angiography or MR angiography). The presence of PCoA atresia, VA hypoplasia, VAs that end in the posterior inferior cerebellar artery (PICA), and extracranial VA occlusion was recorded. 38 BAO patients were included. Mean age was 63±15 years; 52% were men. Baseline National Institutes of Health Stroke Scale score was 21±9, and mean/median time from symptom onset to IAT were 10/7 h. First generation thrombectomy devices were mostly used. Overall Treatment in Cerebral Ischemia 2b-3 reperfusion was 68.4%. Good outcome (modified Rankin Scale score ≤2) was observed in 17.8% and mortality in 64.3% of cases at 90 days. 55% of patients had an atretic PCoA while 47% had a hypoplastic VA. The mean sum of the bilateral PCoA and VA diameters were 2.3±1.2 and 5.2±5.2 mm, respectively. VAs that end in the PICA was noted in 23% of patients, and extracranial VA occlusion in 42%. BAO was proximal/mid/distal in 36%/29%/34%. Multivariate linear regression analysis indicated hypertensive disease (β=2.97; 95% CI 1.15 to 4.79; p<0.01) and reperfusion rate (β=-0.40; 95% CI -0.74 to -0.70; p=0.02) independently associated with outcome. Multivariate analysis for predictors of reperfusion failed to identify other associations. A trend for better reperfusion with stent retrievers was noted (β=1.82; 95% CI -0.24 to 3.88; p=0.08). Reperfusion emerged as a predictor of good outcome in patients that underwent IAT for BAO. Angioarchitectural variations of the posterior circulation were not found to impact reperfusion or clinical outcome. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence

Surgical outcomes of Majewski osteodysplastic primordial dwarfism Type II with intracranial vascular anomalies.

PubMed

Teo, Mario; Johnson, Jeremiah N; Bell-Stephens, Teresa E; Marks, Michael P; Do, Huy M; Dodd, Robert L; Bober, Michael B; Steinberg, Gary K

2016-12-01

OBJECTIVE Majewski osteodysplastic primordial dwarfism Type II (MOPD II) is a rare genetic disorder. Features of it include extremely small stature, severe microcephaly, and normal or near-normal intelligence. Previous studies have found that more than 50% of patients with MOPD II have intracranial vascular anomalies, but few successful surgical revascularization or aneurysm-clipping cases have been reported because of the diminutive arteries and narrow surgical corridors in these patients. Here, the authors report on a large series of patients with MOPD II who underwent surgery for an intracranial vascular anomaly. METHODS In conjunction with an approved prospective registry of patients with MOPD II, a prospectively collected institutional surgical database of children with MOPD II and intracranial vascular anomalies who underwent surgery was analyzed retrospectively to establish long-term outcomes. RESULTS Ten patients with MOPD II underwent surgery between 2005 and 2012; 5 patients had moyamoya disease (MMD), 2 had intracranial aneurysms, and 3 had both MMD and aneurysms. Patients presented with transient ischemic attack (TIA) (n = 2), ischemic stroke (n = 2), intraparenchymal hemorrhage from MMD (n = 1), and aneurysmal subarachnoid hemorrhage (n = 1), and 4 were diagnosed on screening. The mean age of the 8 patients with MMD, all of whom underwent extracranial-intracranial revascularization (14 indirect, 1 direct) was 9 years (range 1-17 years). The mean age of the 5 patients with aneurysms was 15.5 years (range 9-18 years). Two patients experienced postoperative complications (1 transient weakness after clipping, 1 femoral thrombosis that required surgical repair). During a mean follow-up of 5.9 years (range 3-10 years), 3 patients died (1 of subarachnoid hemorrhage, 1 of myocardial infarct, and 1 of respiratory failure), and 1 patient had continued TIAs. All of the surviving patients recovered to their neurological baseline. CONCLUSIONS Patients with MMD

Intracranial pressure monitoring (image)

MedlinePlus

Intracranial pressure monitoring is performed by inserting a catheter into the head with a sensing device to monitor the pressure around the brain. An increase in intracranial pressure can cause a decrease in blood flow to ...

Improved black-blood imaging using DANTE-SPACE for simultaneous carotid and intracranial vessel wall evaluation

PubMed Central

Xie, Yibin; Yang, Qi; Xie, Guoxi; Pang, Jianing; Fan, Zhaoyang; Li, Debiao

2015-01-01

Purpose The purpose of this work is to develop a 3D black-blood imaging method for simultaneously evaluating carotid and intracranial arterial vessel wall with high spatial resolution and excellent blood suppression with and without contrast enhancement. Methods DANTE preparation module was incorporated into SPACE sequence to improve blood signal suppression. Simulations and phantom studies were performed to quantify image contrast variations induced by DANTE. DANTE-SPACE, SPACE and 2D TSE were compared for apparent SNR, CNR and morphometric measurements in fourteen healthy subjects. Preliminary clinical validation was performed in six symptomatic patients. Results Apparent residual luminal blood was observed in 5 (pre-CE) and 9 (post-CE) subjects with SPACE, and only 2 (post-CE) subjects with DANTE-SPACE. DANTE-SPACE showed 31% (pre-CE) and 100% (post-CE) improvement in wall-to-blood CNR over SPACE. Vessel wall area measured from SPACE was significantly larger than that from DANTE-SPACE due to possible residual blood signal contamination. In patients DANTE-SPACE showed the potential to detect vessel wall dissection and identify plaque components. Conclusion DANTE-SPACE significantly improved arterial and venous blood suppression compared with SPACE. Simultaneous high-resolution carotid and intracranial vessel wall imaging to potentially identify plaque components was feasible with scan time under 6 minutes. PMID:26152900

Negative-Pressure Hydrocephalus: A Case Report on Successful Treatment Under Intracranial Pressure Monitoring with Bilateral Ventriculoperitoneal Shunts.

PubMed

Pandey, Sajan; Jin, Yi; Gao, Liang; Zhou, Cheng Cheng; Cui, Da Ming

2017-03-01

Negative-pressure hydrocephalus (NegPH), a very rare condition of unknown etiology and optimal treatment, usually presents postneurosurgery with clinical and imaging features of hydrocephalus, but with negative cerebrospinal fluid pressure. We describe a NegPH case of -3 mm Hg intracranial pressure that was successfully treated to achieve 5 mm Hg under continuous intracranial pressure monitoring with horizontal positioning, head down and legs elevated to 10°-15°, neck wrapping for controlled venous drainage, chest and abdomen bandages, infusion of 5% dextrose fluid to lower plasma osmolarity (Na + , 130-135 mmol/L), daily cerebrospinal fluid drainage >200 mL, and arterial blood gas partial pressure of carbon dioxide >40 mm Hg. Copyright © 2016 Elsevier Inc. All rights reserved.

One-dimensional model for the intracranial pulse morphological analysis during hyperventilation and CO2 inhalation tests

NASA Astrophysics Data System (ADS)

Ryu, Jaiyoung; Hu, Xiao; Shadden, Shawn C.

2015-11-01

The brain's CO2 reactivity mechanism is coupled with cerebral autoregulation and other unique features of cerebral hemodynamics. We developed a one-dimensional nonlinear model of blood flow in the cerebral arteries coupled to lumped parameter (LP) networks. The LP networks incorporate cerebral autoregulation, CO2 reactivity, intracranial pressure, cerebrospinal fluid, and cortical collateral blood flow models. The model was used to evaluate hemodynamic variables (arterial deformation, blood velocity and pressure) in the cerebral vasculature during hyperventilation and CO2 inhalation test. Tests were performed for various arterial blood pressure (ABP) representing normal and hypotensive conditions. The increase of the cerebral blood flow rates agreed well with the published measurements for various ABP measurements taken during clinical CO2 reactivity tests. The changes in distal vasculature affected the reflected pulse wave energy, which caused the waveform morphological changes at the middle cerebral, common and internal carotid arteries. The pulse morphological analysis demonstrated agreement with previous clinical measurements for cerebral vasoconstriction and vasodilation.

Association between arterial calcifications and nonlacunar and lacunar ischemic strokes.

PubMed

van Dijk, Anouk C; Fonville, Susanne; Zadi, Taihra; van Hattem, Antonius M G; Saiedie, Ghesrouw; Koudstaal, Peter J; van der Lugt, Aad

2014-03-01

Nonlacunar cerebral infarcts are presumed to be caused by thromboembolism from the heart or extracranial arteries, whereas lacunar infarcts are thought to be caused by small vessel disease. We investigated to what extent arterial calcifications differ between nonlacunar and lacunar ischemic strokes. We studied 820 consecutive patients with transient ischemic attack or ischemic stroke in the anterior circulation who underwent multidetector computed tomography angiography and had no rare cause of stroke. The presence of likely cardioembolic pathogenesis was determined according to the Trial of Org 10172 in Acute Stroke Treatment criteria. The remaining 708 patients were categorized as nonlacunar or lacunar strokes, either transient ischemic attacks or strokes, based on clinical symptoms corrected by brain imaging results. We measured volume of calcifications in the aortic arch, symptomatic extracranial and intracranial carotid artery using multidetector computed tomography angiography. The difference in calcifications between nonlacunar and lacunar strokes was assessed with a multivariable logistic regression analysis. We adjusted for degree of symptomatic carotid artery stenosis and cardiovascular risk factors. We found an independent association between volume of aortic arch calcifications and nonlacunar ischemic strokes (adjusted odds ratio [95% confidence interval], 1.11 [1.02-1.21]). No independent associations between extracranial and intracranial carotid artery calcifications and nonlacunar strokes were present. The only difference we found between nonlacunar and lacunar strokes was a higher calcification volume in the aortic arch in nonlacunar strokes. Our findings only partially confirm the notion of distinct etiologies and suggest that the potential role of other plaque components, plaque morphology, and aortic arch calcifications in ischemic stroke subtypes awaits further evaluation.

Vertebrobasilar junction giant aneurysm: Lessons learned from a neurosurgical audit and anatomical investigation.

PubMed

Graziano, Francesca; Ganau, Mario; Russo, Vittorio Maria; Iacopino, Domenico G; Ulm, Arthur John

2015-01-01

The treatment of vascular lesions of the vertebrobasilar junction (VBJ) remains a challenging task in the neurosurgical practice and the gold standard therapy is still under debate. In this article, the authors report a detailed postmortem study of a VBJ giant aneurysm (GA) previously endovascularly treated. Although the decision-making process for the vast majority of neurosurgical treatment can nowadays be accurately carried out during the preoperative planning (i.e., with the aid of neuroimaging fusion protocols, neuronavigation platforms, etc.) meant to maximize the anatomical understanding of the lesions and minimize possible intraprocedural challenges, this postmortem study represents the ultimate essence of neurosurgical audit as the laboratory investigations allowed to reevaluate the clinical history of VBJ GA, and reassess the multiple strategies available for its treatment with a straightforward anatomical perspective. Specifically, the lessons learned through this clinical and laboratory work uphold a great educational value regarding the complex management of those lesions, including the possible role of combined skull base surgical approaches.

Randomized controlled trial comparing the effect of 8.4% sodium bicarbonate and 5% sodium chloride on raised intracranial pressure after traumatic brain injury.

PubMed

Bourdeaux, Chris P; Brown, Jules M

2011-08-01

Hypertonic sodium chloride solutions are routinely used to control raised intracranial pressure (ICP) after traumatic brain injury but have the potential to cause a hyperchloremic metabolic acidosis. Sodium bicarbonate 8.4% has previously been shown to reduce ICP and we have therefore conducted a randomized controlled trial to compare these two solutions. Patients with severe traumatic brain injury were randomly allocated to receive an equiosmolar dose of either 100 ml of sodium chloride 5% or 85 ml of sodium bicarbonate 8.4% for each episode of intracranial hypertension. ICP and blood pressure were measured continuously. Arterial pCO(2), sodium, chloride, osmolality, and pH were measured at intervals. We studied 20 episodes of intracranial hypertension in 11 patients. Treatments with 8.4% sodium bicarbonate and 5% sodium chloride reduced raised ICP effectively with a significant fall in ICP from baseline at all time points (P < 0.001). There was no significant difference in ICP with time between those episodes treated with 5% sodium chloride or 8.4% sodium bicarbonate, P = 0.504. Arterial pH was raised after treatment with 8.4% sodium bicarbonate. An equiosmolar infusion of 8.4% sodium bicarbonate is as effective as 5% sodium chloride for reduction of raised ICP after traumatic brain injury when infused over 30 min.

De novo giant A2 aneurysm following anterior communicating artery occlusion.

PubMed

Ibrahim, Tarik F; Hafez, Ahmad; Andrade-Barazarte, Hugo; Raj, Rahul; Niemela, Mika; Lehto, Hanna; Numminen, Jussi; Jarvelainen, Juha; Hernesniemi, Juha

2015-01-01

De novo intracranial aneurysms are reported to occur with varying incidence after intracranial aneurysm treatment. They are purported to be observed, however, with increased incidence after Hunterian ligation; particularly in cases of carotid artery occlusion for giant or complex aneurysms deemed unclippable. We report a case of right-sided de novo giant A2 aneurysm 6 years after an anterior communicating artery (ACoA) aneurysm clipping. We believe this de novo aneurysm developed in part due to patient-specific risk factors but also a significant change in cerebral hemodynamics. The ACoA became occluded after surgery that likely altered the cerebral hemodynamics and contributed to the de novo aneurysm. We believe this to be the first reported case of a giant de novo aneurysm in this location. Following parent vessel occlusion (mostly of the carotid artery), there are no reports of any de novo aneurysms in the pericallosal arteries let alone a giant one. The patient had a dominant right A1 and the sudden increase in A2 blood flow likely resulted in increased wall shear stress, particularly in the medial wall of the A2 where the aneurysm occurred 2 mm distal to the A1-2 junction. ACoA preservation is a key element of aneurysm surgery in this location. Suspected occlusion of this vessel may warrant closer radiographic follow-up in patients with other risk factors for aneurysm development.

Erdheim-Chester Disease Involving the Central Nervous System with the Unique Appearance of a Coated Vertebral Artery.

PubMed

Suzuki, Hime; Wanibuchi, Masahiko; Komatsu, Katsuya; Akiyama, Yukinori; Mikami, Takeshi; Sugita, Shintaro; Hasegawa, Tadashi; Kaya, Mitsunori; Takada, Kohichi; Mikuni, Nobuhiro

2016-10-01

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis. It is characterized by multiple xanthogranulomatous masses throughout the body, predominantly in the tibia. One of the characteristic radiological findings of the lesions associated with ECD is a "coated artery," which is often observed in the aorta. Although approximately one-fourth of ECD cases involve the central nervous system (CNS), an intracranial-coated artery has only been reported in four cases. We report a case of ECD that involves the CNS and has the unique appearance of a coated vertebral artery (VA). These tumors entirely encase the bilateral VAs without stenosis and are attached to the dura. Cranial magnetic resonance imaging also showed multiple extra-axial tumors in the cavernous sinus, the frontal convexity, and the orbital cavity. Further investigation revealed additional extracranial lesions around the cervical carotid artery, at the bilateral tibia, and at the elbow joint. A biopsy of the cervical and tibial lesions confirmed ECD. Steroid therapy resulted in a month-long improvement of preoperative symptoms. However, the patient's condition gradually progressed and he died of pneumonia 1 year after ECD diagnosis. The encasement of the intracranial artery by the tumor without stenosis and the dural attachment suggest ECD, which requires whole body investigation.

Erdheim-Chester Disease Involving the Central Nervous System with the Unique Appearance of a Coated Vertebral Artery

PubMed Central

Suzuki, Hime; Wanibuchi, Masahiko; Komatsu, Katsuya; Akiyama, Yukinori; Mikami, Takeshi; Sugita, Shintaro; Hasegawa, Tadashi; Kaya, Mitsunori; Takada, Kohichi; Mikuni, Nobuhiro

2016-01-01

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis. It is characterized by multiple xanthogranulomatous masses throughout the body, predominantly in the tibia. One of the characteristic radiological findings of the lesions associated with ECD is a “coated artery,” which is often observed in the aorta. Although approximately one-fourth of ECD cases involve the central nervous system (CNS), an intracranial-coated artery has only been reported in four cases. We report a case of ECD that involves the CNS and has the unique appearance of a coated vertebral artery (VA). These tumors entirely encase the bilateral VAs without stenosis and are attached to the dura. Cranial magnetic resonance imaging also showed multiple extra-axial tumors in the cavernous sinus, the frontal convexity, and the orbital cavity. Further investigation revealed additional extracranial lesions around the cervical carotid artery, at the bilateral tibia, and at the elbow joint. A biopsy of the cervical and tibial lesions confirmed ECD. Steroid therapy resulted in a month-long improvement of preoperative symptoms. However, the patient’s condition gradually progressed and he died of pneumonia 1 year after ECD diagnosis. The encasement of the intracranial artery by the tumor without stenosis and the dural attachment suggest ECD, which requires whole body investigation. PMID:28664013

Risk Factors for the Rupture of Intracranial Aneurysms Using Computed Tomography Angiography.

PubMed

Wang, Guang-Xian; Wen, Li; Yang, Liu; Zhang, Qi-Chuang; Yin, Jin-Bo; Duan, Chun-Mei; Zhang, Dong

2018-02-01

To study the clinical and morphologic characteristics associated with risk factors for the rupture of intracranial aneurysms (IAs). A total of 1115 consecutive patients with 1282 IAs were reviewed from August 2011 to February 2016. The patients and IAs were divided into ruptured and unruptured groups. Based on the clinical and morphologic findings, the risk factors for IA rupture were assessed using statistical methods. Age, hypertension, diabetes mellitus, and cerebral atherosclerosis were associated with ruptured IAs. IAs located in the anterior cerebral artery, the anterior communicating artery, the posterior communicating artery, and the internal carotid artery were associated with ruptured IAs. Ruptures were also associated with arterial bifurcations, irregular aneurysm shapes, and all continuous data, except neck width. Binary logistic regression showed that IAs located at bifurcations (odds ratio [OR], 1.804), with irregular shapes (OR, 4.677), with high aspect ratios (ARs) (OR, 5.037) or with small mean diameters (MDs) (OR, 0.495) are more prone to rupture. Receiver operating characteristic analysis showed that the threshold values of the AR and MD were 1 and 3.70 mm, respectively. Morphologic characteristics, such as being located at bifurcations, being irregularly shaped, having a high AR (>1), and having a small MD (<3.70 mm), were better predictors of rupture. Copyright © 2017 Elsevier Inc. All rights reserved.

A murine model of targeted infusion for intracranial tumors.

PubMed

Kim, Minhyung; Barone, Tara A; Fedtsova, Natalia; Gleiberman, Anatoli; Wilfong, Chandler D; Alosi, Julie A; Plunkett, Robert J; Gudkov, Andrei; Skitzki, Joseph J

2016-01-01

Historically, intra-arterial (IA) drug administration for malignant brain tumors including glioblastoma multiforme (GBM) was performed as an attempt to improve drug delivery. With the advent of percutaneous neuorovascular techniques and modern microcatheters, intracranial drug delivery is readily feasible; however, the question remains whether IA administration is safe and more effective compared to other delivery modalities such as intravenous (IV) or oral administrations. Preclinical large animal models allow for comparisons between treatment routes and to test novel agents, but can be expensive and difficult to generate large numbers and rapid results. Accordingly, we developed a murine model of IA drug delivery for GBM that is reproducible with clear readouts of tumor response and neurotoxicities. Herein, we describe a novel mouse model of IA drug delivery accessing the internal carotid artery to treat ipsilateral implanted GBM tumors that is consistent and reproducible with minimal experience. The intent of establishing this unique platform is to efficiently interrogate targeted anti-tumor agents that may be designed to take advantage of a directed, regional therapy approach for brain tumors.

Stent-Assisted Endovascular Treatment of Anterior Communicating Artery Aneurysms - Literature Review.

PubMed

Kocur, Damian; Ślusarczyk, Wojciech; Przybyłko, Nikodem; Bażowski, Piotr; Właszczuk, Adam; Kwiek, Stanisław

2016-01-01

The anterior cerebral artery is a common location of intracranial aneurysms. The standard coil embolization technique is limited by its inability to occlude wide-neck aneurysms. Stent deployment across the aneurysm neck supports the coil mass inside the aneurysmal sac, and furthermore, has an effect on local hemodynamic and biologic changes. In this article, various management strategies and techniques as well as angiographic outcomes and complications related to stent-assisted endovascular treatment of anterior communicating artery aneurysms are presented. This treatment method is safe and associated with low morbidity and mortality rates.

Endovascular treatment of distal intracranial aneurysms with Onyx 18/34.

PubMed

Chalouhi, Nohra; Tjoumakaris, Stavropoula; Gonzalez, L Fernando; Hasan, David; Alkhalili, Kenan; Dumont, Aaron S; Rosenwasser, Robert; Jabbour, Pascal

2013-12-01

Surgical clipping and coil embolization of distally located intracranial aneurysms can be challenging. The goal of this study was to assess the feasibility, safety and efficacy of treatment of distal aneurysms with the liquid embolic agent Onyx 18/34. Sixteen patients were treated with Onyx 18/34 for distally located aneurysms in our institution between March 2009 and September 2012. The technique consists of occluding the aneurysm as well as the parent vessel at the level of aneurysm with Onyx 18 or 34. Candidates for this treatment were patients with distal aneurysms including mycotic aneurysms, dissecting aneurysms, and pseudoaneurysms in which coiling was considered impossible. Of the 16 patients, 12 presented with subarachnoid and/or intracerebral hemorrhage. Median aneurysm size was 4.6mm. Aneurysm locations were as follows: Posterior inferior cerebellar artery (n=5), distal anterior inferior cerebellar artery (n=3), distal pericallosal (n=3), distal anterior cerebral artery (n=3), lenticulostriate artery (n=1), and anterior ethmoidal artery (n=1). There were 4 mycotic aneurysms. Complete aneurysm obliteration was achieved in all 6 patients with available angiographic follow-up. There was only 1 (6.3%) symptomatic complication in the series. There were no instances of reflux or accidental migration of embolic material. Favorable outcomes were noted in 82% of patients at discharge. Two patients with mycotic aneurysms died from cardiac complications of endocarditis. No aneurysm recanalization or rehemorrhage were seen. Parent vessel trapping with Onyx 18/34 offers a simple, safe, and effective means of achieving obliteration of distal challenging aneurysms. Copyright © 2013 Elsevier B.V. All rights reserved.

Current management of symptomatic intracranial stenosis.

PubMed

Taylor, Robert A; Weigele, John B; Kasner, Scott E

2011-08-01

Intracranial arterial stenosis (IAS) is the cause of about 10% of all ischemic strokes in the United States, but may account for about 40% of strokes in some populations. After a stroke or transient ischemic attack due to IAS, patients face a 12% annual risk of recurrent stroke on medical therapy, with most strokes occurring in the first year. Warfarin is no better than aspirin in preventing recurrent strokes but poses a higher risk of serious bleeding and death. Groups with the highest risk of recurrent stroke are those with high-grade (≥ 70%) stenosis, those with recent symptom onset, those with symptoms precipitated by hemodynamic maneuvers, and women. Endovascular treatment of IAS is a rapidly evolving therapeutic option. Antiplatelet agents are currently recommended as the primary treatment for symptomatic IAS, with endovascular therapy reserved for appropriate high-risk cases refractory to medical therapy.

Preoperative assessment of intracranial tumors with perfusion MR and a volumetric interpolated examination: a comparative study with DSA.

PubMed

Wetzel, Stephan G; Cha, Soonmee; Law, Meng; Johnson, Glyn; Golfinos, John; Lee, Peter; Nelson, Peter Kim

2002-01-01

In evaluating intracranial tumors, a safe low-cost alternative that provides information similar to that of digital subtraction angiography (DSA) may be of interest. Our purpose was to determine the utility and limitations of a combined MR protocol in assessing (neo-) vascularity in intracranial tumors and their relation to adjacent vessels and to compare the results with those of DSA. Twenty-two consecutive patients with an intracranial tumor who underwent preoperative stereoscopic DSA were examined with contrast-enhanced dynamic T2*-weighted perfusion MR imaging followed by a T1-weighted three-dimensional (3D) MR study (volumetric interpolated brain examination [VIBE]). The maximum relative cerebral blood volume (rCBV) of the tumor was compared with tumor vascularity at DSA. Critical vessel structures were defined in each patient, and VIBE images of these structures were compared with DSA findings. For full exploitation of the 3D data sets, maximum-intensity projection algorithms reconstructed in real time with any desired volume and orientation were used. Tumor blush scores at DSA were significantly correlated with the rCBV measurements (r = 0.75; P <.01, Spearman rank correlation coefficient). In 17 (77%) patients, VIBE provided all relevant information about the venous system, whereas information about critical arteries were partial in 50% of the cases and not relevant in the other 50%. A fast imaging protocol consisting of perfusion MR imaging and a volumetric MR acquisition provides some of the information about tumor (neo-) vascularity and adjacent vascular anatomy that can be obtained with conventional angiography. However, the MR protocol provides insufficient visualization of distal cerebral arteries.

Surgical flow modification of the anterior cerebral artery-anterior communicating artery complex in the management of giant aneurysms of internal carotid artery bifurcation: An alternative for a difficult clip reconstruction

PubMed Central

Pahl, Felix Hendrik; de Oliveira, Matheus Fernandes; Beer-Furlan, André Luiz; Rotta, José Marcus

2016-01-01

Background: Internal carotid artery bifurcation (ICAb) aneurysms account for about 2–15% of all intracranial aneurysms. In giant and complex cases, treatment may be difficult and dangerous, once some aneurysms have wide neck and anterior cerebral artery (ACA) and middle cerebral artery (MCA) may arise from the aneurysm itself. Clip reconstruction may be difficult in such cases. Whenever possible, the occlusion of ACA transform the bifurcation in a single artery reconstruction (ICA to MCA), much easier than a bifurcation reconstruction. Methods: In patients with giant and complex ICAb aneurysms, we propose routine preoperative angiography with anatomical evaluation of anterior communicating artery (ACoA) patency during cervical common carotid compression with concomitant contralateral carotid artery injection. This allowed visualization of the expected reversal of flow in the A1 segment–ACoA complex. When test is positive, we can perform ipsilateral ACA (A1 segment) clip occlusion and flow modification of the ACA-ACoA complex transforming a three vessel (ICA, ACA, and MCA) reconstruction into a two vessel (ICA and MCA) reconstruction. Results: Two patients were treated, with 100% of occlusion and good outcome. Conclusions: Surgical treatment of giant and complex ICAb may be achieved with acceptable morbidity. PMID:27313968

Successful flow reduction surgery for a ruptured true posterior communicating artery aneurysm caused by the common carotid artery ligation for epistaxis

PubMed Central

Yamao, Yukihiro; Takahashi, Jun C.; Satow, Tetsu; Iihara, Koji; Miyamoto, Susumu

2014-01-01

Background: Carotid artery occlusion can lead to the development of rare true posterior communicating artery (PCoA) aneurysms because of hemodynamic stress on the PCoA. Surgical treatment of these lesions is challenging. Case Description: The authors report a case of a true PCoA aneurysm that developed and ruptured 37 years after ligation of the ipsilateral common carotid artery for epistaxis. The lesion was successfully treated with clipping of the distal M1 segment of the middle cerebral artery (MCA) after the occipital artery-radial artery free graft-MCA bypass, which led to extreme reduction in collateral flow through the PCoA. A cortical branch, located just proximal to the obliteration site, functioned as a sufficient flow outlet. The aneurysm shrank, and the patient has been doing well without any symptoms for 5 years after surgery. Conclusions: M1 obliteration combined with high-flow extra-intracranial bypass might be a promising option for a true PCoA aneurysm, and therapeutic design that leaves a sufficient flow outlet on the M1 is mandatory to avoid unexpected occlusion of the M1 and its perforators. PMID:25525556

Characteristics and Outcomes of Patients with Anterior Circulation Intracranial Aneurysm Managed with Clipping in Hospital Sungai Buloh.

PubMed

Ab Ghani, Ailani; Nayan, Saiful Azli Mat; Kandasamy, Regunath; Rosman, Azmin Kas; Ghani, Abdul Rahman Izani

2016-11-01

The annual incidence of intracranial aneurysm in Malaysia is estimated to be 1.1-1.7 per 100,000 population based on a study done conducted in 1988. Since then, little epidemiological research has been conducted in Malaysia, and the real incidence is therefore probably unreported despite advancements in the diagnosis and treatment of this disorder. Intracranial aneurysm may be treated by microsurgical clipping or embolisation depending on its location and the surgeon's preference. This study aims to report the characteristics and outcomes of patients with a clipped anterior circulation aneurysm in Hospital Sungai Buloh. We retrospectively collected the data of patients with anterior circulation aneurysms who underwent clipping from 1 January 2013 until 30 June 2014 in Hospital Sungai Buloh. The mean age of the patients was 48.9 years old, and 56.7% of the study population were male and 63.3% were Malay. There were almost equal numbers of patients with (46.7%) and without (53.3%) co-morbidities such as hypertension and ischaemic heart disease. Half of the study population fell under Fisher grade 3 (50.0%), whereas 46.7% were Fisher grade 4. With respect to the Navarro score, 20% of patients scored 10, 16.7% scored 5 or 7, 13.3% scored 11, 10% scored 9, 6.7% scored 1 and 3.3% scored 2, 3 or 8. Most of the patients fell under grade I (33.3%) of the World Federation of Neurological Societies grading (WFNS), and the fewest number of patients were grade III (3.3%). Most (56.7%) patients had an intracranial aneurysm located at the anterior communicating artery (ACOM), followed by the anterior cerebral artery (ACA) and the middle cerebral artery (MCA) (16.7% each), the posterior communicating artery (PCOM) (6.7%) and, finally, the internal carotid artery (ICA) (3.3%). Neurological outcomes at three and six months were assessed using the Modified Rankin Scale (mRS). At three months follow-up, the majority of the participants (33.3%) scored 0 or 6, whereas at six months

Bedside Optic Nerve Sheath Diameter Assessment in the Identification of Increased Intracranial Pressure in Suspected Idiopathic Intracranial Hypertension.

PubMed

Irazuzta, Jose E; Brown, Martha E; Akhtar, Javed

2016-01-01

We determined whether the bedside assessment of the optic nerve sheath diameter could identify elevated intracranial pressure in individuals with suspected idiopathic intracranial hypertension. This was a single-center, prospective, rater-blinded study performed in a freestanding pediatric teaching hospital. Patients aged 12 to 18 years scheduled for an elective lumbar puncture with the suspicion of idiopathic intracranial hypertension were eligible to participate. Optic nerve sheath diameter was measured via ultrasonography before performing a sedated lumbar puncture for measuring cerebrospinal fluid opening pressure. Abnormal measurements were predefined as optic nerve sheath diameter ≥4.5 mm and a cerebrospinal fluid opening pressure greater than 20 cmH2O. Thirteen patients participated in the study, 10 of whom had elevated intracranial pressure. Optic nerve sheath diameter was able to predict or rule out elevated intracranial pressure in all patients. Noninvasive assessment of the optic nerve sheath diameter could help to identify patients with elevated intracranial pressure when idiopathic intracranial hypertension is suspected. Copyright © 2016 Elsevier Inc. All rights reserved.

Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension

PubMed Central

Godoy, Daniel Agustín; Seifi, Ali; Garza, David; Lubillo-Montenegro, Santiago; Murillo-Cabezas, Francisco

2017-01-01

During traumatic brain injury, intracranial hypertension (ICH) can become a life-threatening condition if it is not managed quickly and adequately. Physicians use therapeutic hyperventilation to reduce elevated intracranial pressure (ICP) by manipulating autoregulatory functions connected to cerebrovascular CO2 reactivity. Inducing hypocapnia via hyperventilation reduces the partial pressure of arterial carbon dioxide (PaCO2), which incites vasoconstriction in the cerebral resistance arterioles. This constriction decrease cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient’s ICP. The effects of therapeutic hyperventilation (HV) are transient, but the risks accompanying these changes in cerebral and systemic physiology must be carefully considered before the treatment can be deemed advisable. The most prominent criticism of this approach is the cited possibility of developing cerebral ischemia and tissue hypoxia. While it is true that certain measures, such as cerebral oxygenation monitoring, are needed to mitigate these dangerous conditions, using available evidence of potential poor outcomes associated with HV as justification to dismiss the implementation of therapeutic HV is debatable and remains a controversial subject among physicians. This review highlights various issues surrounding the use of HV as a means of controlling posttraumatic ICH, including indications for treatment, potential risks, and benefits, and a discussion of what techniques can be implemented to avoid adverse complications. PMID:28769857

[Severe rhabdomyolysis and intracranial hemorrhage associated with synthetic cannabinoid: a case report].

PubMed

Tanei, Takafumi; Morita, Yoshiki; Yashima, Akihito; Wakita, Hiroyuki; Takebayashi, Shigenori; Nakahara, Norimoto; Wakabayashi, Toshihiko

2014-09-01

A 28-year-old male presented with language and behavior disorders a few days prior to examination. Magnetic resonance images and cerebral angiography revealed an arteriovenous malformation (AVM) in the right frontal lobe. The size of the nidus was 2.0 cm, and it was fed by the middle cerebral arteries and drained by the superior sagittal and transverse sinuses. The AVM was completely surgically resected without any complications. Ten months after the surgery, the patient presented with behavior disorders again and general convulsion. Computed tomography showed a small intracranial hemorrhage at the right frontal lobe, where the AVM was located. Blood examination revealed severe rhabdomyolysis (CK:536,620U/L)and acute kidney injury (Cr:5.20mg/dL). After admission, it became clear that the patient had used synthetic cannabinoid (SC). SC refers to a variety of herbal/chemical mixtures, which mimic the effects of marijuana. Little data is available on the psychopathological and physical effects of SC. This is the first report of severe rhabdomyolysis and intracranial hemorrhage associated with SC use in Japan.

Comparison of eye-lens doses imparted during interventional and non-interventional neuroimaging techniques for assessment of intracranial aneurysms.

PubMed

Guberina, N; Dietrich, U; Forsting, M; Ringelstein, A

2018-02-01

A neurointerventional examination of intracranial aneurysms often involves the eye lens in the primary beam of radiation. To assess and compare eye-lens doses imparted during interventional and non-interventional imaging techniques for the examination of intracranial aneurysms. We performed a phantom study on an anthropomorphic phantom (ATOM dosimetry phantom 702-D; CIRS, Norfolk, Virginia, USA) and assessed eye-lens doses with thermoluminescent dosimeters (TLDs) type 100 (LiF:Mg, Ti) during (1) interventional (depiction of all cerebral arteries with triple 3D-rotational angiography and twice 2-plane DSA anteroposterior and lateral projections) and (2) non-interventional (CT angiography (CTA)) diagnosis of intracranial aneurysms. Eye-lens doses were calculated following recommendations of the ICRP 103. Image quality was analysed in retrospective by two experienced radiologists on the basis of non-interventional and interventional pan-angiography examinations of patients with incidental aneurysms (n=50) on a five-point Likert scale. The following eye-lens doses were assessed: (1) interventional setting (triple 3D-rotational angiography and twice 2-plane DSA anteroposterior and lateral projections) 12 mGy; (2) non-interventional setting (CTA) 4.1 mGy. Image quality for depiction of intracranial aneurysms (>3 mm) was evaluated as good by both readers for both imaging techniques. Eye-lens doses are markedly higher during the interventional than during the non-interventional diagnosis of intracranial aneurysms. For the eye-lens dose, CTA offers considerable radiation dose savings in the diagnosis of intracranial aneurysms. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

The clinical spectrum of unruptured intracranial aneurysms.

PubMed

Raps, E C; Rogers, J D; Galetta, S L; Solomon, R A; Lennihan, L; Klebanoff, L M; Fink, M E

1993-03-01

A retrospective study was performed to delineate the clinical characteristics of symptomatic unruptured aneurysms. Patient histories, operative reports, and angiograms in 111 patients with 132 unruptured aneurysms were reviewed. Tertiary care university hospital. One hundred eleven patients with 132 unruptured intracranial aneurysms were studied. There were 85 women and 26 men, with a mean age of 51.2 years (age range, 11 to 77 years). Many patients were referred by community neurologists and neurosurgeons for further evaluation and neurosurgical management. Fifty-four symptomatic patients were identified. Group 1 (n = 19; mean aneurysm diameter, 2.1 cm) had acute symptoms: ischemia (n = 7), headache (n = 7), seizure (n = 3), and cranial neuropathy (n = 2). Group 2 (n = 35; mean aneurysm diameter, 2.2 cm) had chronic symptoms attributed to mass effect: headache (n = 18), visual loss (n = 10), pyramidal tract dysfunction (n = 4), and facial pain (n = 3). Group 3 (n = 57; mean aneurysm diameter, 1.1 cm) had asymptomatic aneurysms. Acute severe headache, comparable to subarachnoid hemorrhage headache, but without nuchal rigidity, was associated with the following mechanisms: aneurysm thrombosis, localized meningeal inflammation, and unexplained. Unruptured aneurysms may be misdiagnosed as optic neuritis or migraine, or serve as a nidus for cerebral thromboembolic events. Internal carotid artery and posterior circulation aneurysms were more likely to cause focal symptoms from mass effect than were anterior cerebral artery and middle cerebral artery aneurysms. Weeks to years may elapse before their diagnosis. The absence of subarachnoid blood does not exclude an aneurysm as a cause for acute or chronic neurologic symptoms.

Successful Treatment with Microvascular Decompression Surgery of a Patient with Hemiparesis Caused by Vertebral Artery Compression of the Medulla Oblongata: Case Report and Review of the Literature.

PubMed

Ren, Jibin; Sun, Hongtao; Diao, Yunfeng; Niu, Xuegang; Wang, Hang; Wei, Zhengjun; Yuan, Fei

2017-12-01

There are few reports on hemiparesis caused by vascular medullary compression, which can occur because of dolichoectasia of the vertebrobasilar arterial system. In this article, we report a case of vertebral artery compression of the medulla oblongata in a 67-year-old woman. The patient was hypertensive, and she developed hemiparesis and intermittent spasms over 5 years. These spasms had worsened during the last year. Cranial nerve magnetic resonance imaging showed compression of the medulla oblongata by the left vertebral artery. A motor evoked potential (MEP) examination showed abnormal conduction of MEPs of bilateral toe abductors. The patient underwent microvascular decompression surgery under general anesthesia through a retrosigmoid keyhole approach. This operation led to relief of vascular compression and symptomatic improvement. Our case suggests that detailed history, imaging studies, and electrophysiologic studies help lead to a correct and early diagnosis of hemiparesis caused by vascular compression of the rostral ventrolateral medulla. Microvascular decompression surgery improves patient symptoms, and intraoperative electrophysiologic monitoring helps to avoid injury to important adjacent nerves. Copyright © 2017 Elsevier Inc. All rights reserved.

Monitoring intracranial pressure based on F-P

NASA Astrophysics Data System (ADS)

Cai, Ting; Tong, Xinglin; Chen, Guangxi

2013-09-01

Intracranial pressure is an important monitoring indicator of neurosurgery. In this paper we adopt all-fiber FP fiber optic sensor, using a minimally invasive operation to realize real-time dynamic monitoring intracranial pressure of the hemorrhage rats, and observe their intracranial pressure regularity of dynamic changes. Preliminary results verify the effectiveness of applications and feasibility, providing some basis for human brain minimally invasive intracranial pressure measurement.

Noninvasive Intracranial Pressure Determination in Patients with Subarachnoid Hemorrhage.

PubMed

Noraky, James; Verghese, George C; Searls, David E; Lioutas, Vasileios A; Sonni, Shruti; Thomas, Ajith; Heldt, Thomas

2016-01-01

Intracranial pressure (ICP) should ideally be measured in many conditions affecting the brain. The invasiveness and associated risks of the measurement modalities in current clinical practice restrict ICP monitoring to a small subset of patients whose diagnosis and treatment could benefit from ICP measurement. To expand validation of a previously proposed model-based approach to continuous, noninvasive, calibration-free, and patient-specific estimation of ICP to patients with subarachnoid hemorrhage (SAH), we made waveform recordings of cerebral blood flow velocity in several major cerebral arteries during routine, clinically indicated transcranial Doppler examinations for vasospasm, along with time-locked waveform recordings of radial artery blood pressure (APB), and ICP was measured via an intraventricular drain catheter. We also recorded the locations to which ICP and ABP were calibrated, to account for a possible hydrostatic pressure difference between measured ABP and the ABP value at a major cerebral vessel. We analyzed 21 data records from five patients and were able to identify 28 data windows from the middle cerebral artery that were of sufficient data quality for the ICP estimation approach. Across these windows, we obtained a mean estimation error of -0.7 mmHg and a standard deviation of the error of 4.0 mmHg. Our estimates show a low bias and reduced variability compared with those we have reported before.

Role of Multimodal Evaluation of Cerebral Hemodynamics in Selecting Patients with Symptomatic Carotid or Middle Cerebral Artery Steno-occlusive Disease for Revascularization

PubMed Central

Sharma, Vijay K; Tsivgoulis, Georgios; Ning, Chou; Teoh, Hock L; Bairaktaris, Chrisostomos; Chong, Vincent FH; Ong, Benjamin KC; Chan, Bernard PL; Sinha, Arvind K

2008-01-01

Background: The circle of Willis provides collateral pathways to perfuse the affected vascular territories in patients with severe stenoocclusive disease of major arteries. The collateral perfusion may become insufficient in certain physiological circumstances due to failed vasodilatory reserve and intracranial steal phenomenon, so-called ‘Reversed-Robinhood syndrome’. We evaluated cerebral hemodynamics and vasodilatory reserve in patients with symptomatic distal internal carotid (ICA) or middle cerebral artery (MCA) severe steno-occlusive disease. Methods: Diagnostic transcranial Doppler (TCD) and TCD-monitoring with voluntary breath-holding according to a standard scanning protocol were performed in patients with severe ICA or MCA steno-occlusive disease. The steal phenomenon was detected as transient, spontaneous, or vasodilatory stimuli-induced velocity reductions in affected arteries at the time of velocity increase in normal vessels. Patients with exhausted vasomotor reactivity and intracranial steal phenomenon during breath-holding were further evaluated by 99technetiumm-hexamethyl propylene amine oxime single photon emission computed tomography (HMPAO-SPECT) with acetazolamide challenge. Results: Sixteen patients (age 27–74 years, 11 men) fulfilled our TCD criteria for exhausted vasomotor reactivity and intracranial steal phenomenon during the standard vasomotor testing by breath holding. Acetazolamide-challenged HMPAO-SPECT demonstrated significant hypoperfusion in 12 patients in affected arterial territories, suggestive of failed vasodilatory reserve. A breath-holding index of ≤0.3 on TCD was associated with an abnormal HMPAO-SPECT with acetazolamide challenge. TCD findings of a breath holding index of ≤0.3 and intracranial steal during the procedure were determinants of a significant abnormality on HMPAO-SPECT with acetazolamide challenge. Conclusion: Multimodal evaluation of cerebral hemodynamics in symptomatic patients with severe steno

Stent-Assisted Endovascular Treatment of Anterior Communicating Artery Aneurysms – Literature Review

PubMed Central

Kocur, Damian; Ślusarczyk, Wojciech; Przybyłko, Nikodem; Bażowski, Piotr; Właszczuk, Adam; Kwiek, Stanisław

2016-01-01

Summary The anterior cerebral artery is a common location of intracranial aneurysms. The standard coil embolization technique is limited by its inability to occlude wide-neck aneurysms. Stent deployment across the aneurysm neck supports the coil mass inside the aneurysmal sac, and furthermore, has an effect on local hemodynamic and biologic changes. In this article, various management strategies and techniques as well as angiographic outcomes and complications related to stent-assisted endovascular treatment of anterior communicating artery aneurysms are presented. This treatment method is safe and associated with low morbidity and mortality rates. PMID:27559426

Macrovascular Decompression of Facial Nerve With Anteromedial Transposition of a Dolichoectatic Vertebral Artery: 3-Dimensional Operative Video.

PubMed

Tabani, Halima; Yousef, Sonia; Burkhardt, Jan-Karl; Gandhi, Sirin; Benet, Arnau; Lawton, Michael T

2018-05-21

Most cranial nerve compression syndromes (ie, trigeminal neuralgia and hemifacial spasm) are caused by small arteries impinging on a nerve and are relieved by microvascular decompression. Rarely, cranial nerve compression syndromes can be caused by large artery impingement and can be relieved by macrovascular decompression. When present, this compression often occurs in association with degenerative atherosclerosis in the vertebral arteries (VA) and basilar artery. Conservative treatment is recommended for mild forms, but surgical transposition of the VA away from the root entry zone (REZ) can be considered. This video demonstrates macrovascular decompression of a dolichoectatic VA in a 74-yr-old female with refractory left hemifacial spasm. After obtaining IRB approval, patient consent was sought for the procedure. With the patient in three-quarter-prone position, a far-lateral craniotomy was performed. The dentate ligament was cut to free the VA, and the suprahypoglossal portion of the vagoaccessory triangle was widened. VA compressed the REZ of the facial nerve, but was mobilized anteromedially off the REZ. A muslin sling was wrapped around the VA and its tail brought down to the clival dura, which was punctured with a 19-gauge needle and enlarged with a dissector. The sling was pulled anteromedially to this puncture site and secured to the dura with an aneurysm clip, relieving the REZ of all compression. The patient tolerated the procedure with mild, transient hoarseness and her hemifacial spasm resolved completely. This case demonstrates the macrovascular decompression technique with anteromedial transposition of the vertebrobasilar artery, which can also be used for trigeminal neuralgia.

Intracranial arterial wall imaging using three-dimensional high isotropic resolution black blood MRI at 3.0 Tesla.

PubMed

Qiao, Ye; Steinman, David A; Qin, Qin; Etesami, Maryam; Schär, Michael; Astor, Brad C; Wasserman, Bruce A

2011-07-01

To develop a high isotropic-resolution sequence to evaluate intracranial vessels at 3.0 Tesla (T). Thirteen healthy volunteers and 4 patients with intracranial stenosis were imaged at 3.0T using 0.5-mm isotropic-resolution three-dimensional (3D) Volumetric ISotropic TSE Acquisition (VISTA; TSE, turbo spin echo), with conventional 2D-TSE for comparison. VISTA was repeated for 6 volunteers and 4 patients at 0.4-mm isotropic-resolution to explore the trade-off between SNR and voxel volume. Wall signal-to-noise-ratio (SNR(wall) ), wall-lumen contrast-to-noise-ratio (CNR(wall-lumen) ), lumen area (LA), wall area (WA), mean wall thickness (MWT), and maximum wall thickness (maxWT) were compared between 3D-VISTA and 2D-TSE sequences, as well as 3D images acquired at both resolutions. Reliability was assessed by intraclass correlations (ICC). Compared with 2D-TSE measurements, 3D-VISTA provided 58% and 74% improvement in SNR(wall) and CNR(wall-lumen) , respectively. LA, WA, MWT and maxWT from 3D and 2D techniques highly correlated (ICCs of 0.96, 0.95, 0.96, and 0.91, respectively). CNR(wall-lumen) using 0.4-mm resolution VISTA decreased by 27%, compared with 0.5-mm VISTA but with reduced partial-volume-based overestimation of wall thickness. Reliability for 3D measurements was good to excellent. The 3D-VISTA provides SNR-efficient, highly reliable measurements of intracranial vessels at high isotropic-resolution, enabling broad coverage in a clinically acceptable time. Copyright © 2011 Wiley-Liss, Inc.

Intracranial Hypertension: Medication and Surgery

MedlinePlus

... and surgery in an effort to control their intracranial pressure. Drug Therapy Carbonic Anhydrase Inhibitors Carbonic anhydrase is ... suppressed, production of CSF decreases, which also lowers intracranial pressure. The most common carbonic anhydrase inhibitor and the ...

[Experimental study of acute brain swelling under acute intracranial hypertension (author's transl)].

PubMed

Shigemori, M; Watanabe, M; Kuramoto, S

1976-12-01

There are many problems about the cause, pathophysiology and treatment of acute brain swelling under intracranial hypertension frequently encountered in the neurosurgical clinics. Generally, rapid increase of the cerebral vasoparesis caused by unknown etiology is thought to be the main cause of acute brain swelling under intracranial hypertension. Moreover, disturbance of the cerebral venous circulatory system is discussed recently by many authors. But, research from the point of systemic respiration and hemodynamics is necessary for resolving these problems. This experiment was designed to study the effects of respiration and hemodynamics on the cerebral vasoparesis. Using 22 adult dogs, acute intracranial hypertension was produced by epidural balloon inflation sustained at the level of 300 - 400 mmH2O. Simultaneously with measurement of intracranial pressure at the epidural space, superior sagittal sinus pressure, respirogram, systemic blood pressure (femoral artery), central venous pressure, common carotid blood flow, EKG and bipolar lead EEG were monitored continuously. The experimental group was divided by the respiratory loading into 5 groups as follows: control (6 cases), 10% CO2 hypercapnia (4 cases), 10% O2 hypoxia (4 cases), stenosis of airway (5 cases), 100% O2-controled respiration (3 cases). 1) Cerebral vasoparesis under acute intracranial hypertension took place earlier and showed more rapid progression in groups of stenosis of airway, hypercapnia and hypoxia than control group of spontaneous respiration in room air. No occurrence of cerebral vasoparesis was found out in a group of 100% O2 controlled respiration. It is proved that increased airway resistance or asphyxia, hypercapnia and hypoxia have strictly reference to the occurrence and progression of cerebral vasoparesis and for the prevention of cerebral vasoparesis, correct 100% O2 cont rolled respiration is effective. 2) From the hemodynamic change, the progression of rapid increase of cerebral

Intracranial aneurysm and arachnoid cyst: just a coincidence? A case report.

PubMed

Aguiar, Guilherme Brasileiro de; Santos, Rafael Gomes Dos; Paiva, Aline Lariessy Campos; Silva, João Miguel de Almeida; Silva, Rafael Carlos da; Veiga, José Carlos Esteves

2017-12-18

Presence of an arachnoid cyst and a non-ruptured intracystic brain aneurysm is extremely rare. The aim of this paper was to describe a case of a patient with an arachnoid cyst and a non-ruptured aneurysm inside it. Clinical, surgical and radiological data were analyzed and the literature was reviewed. A patient complained of chronic headache. She was diagnosed as having a temporal arachnoid cyst and a non-ruptured middle cerebral artery aneurysm inside it. Surgery was performed to clip the aneurysm and fenestrate the cyst. This report raises awareness about the importance of intracranial vascular investigation in patients with arachnoid cysts and brain hemorrhage.

Investigating the influence of haemodynamic stimuli on intracranial aneurysm inception.

PubMed

Chen, Haoyu; Selimovic, Alisa; Thompson, Harry; Chiarini, Alessandro; Penrose, Justin; Ventikos, Yiannis; Watton, Paul N

2013-07-01

We propose a novel method to reconstruct the hypothetical geometry of the healthy vasculature prior to intracranial aneurysm (IA) formation: a Frenet frame is calculated along the skeletonization of the arterial geometry; upstream and downstream boundaries of the aneurysmal segment are expressed in terms of the local Frenet frame basis vectors; the hypothetical healthy geometry is then reconstructed by propagating a closed curve along the skeleton using the local Frenet frames so that the upstream boundary is smoothly morphed into the downstream boundary. This methodology takes into account the tortuosity of the arterial vasculature and requires minimal user subjectivity. The method is applied to 22 clinical cases depicting IAs. Computational fluid dynamic simulations of the vasculature without IA are performed and the haemodynamic stimuli in the location of IA formation are examined. We observe that locally elevated wall shear stress (WSS) and gradient oscillatory number (GON) are highly correlated (20/22 for WSS and 19/22 for GON) with regions susceptible to sidewall IA formation whilst haemodynamic indices associated with the oscillation of the WSS vectors have much lower correlations.

Perspective: Update on Idiopathic Intracranial Hypertension

PubMed Central

Bruce, Beau B.; Biousse, Valérie; Newman, Nancy J.

2011-01-01

Purpose Provide an update on various features of idiopathic intracranial hypertension. Design Perspective. Methods Selected articles on the epidemiology, clinical and imaging features, natural history, pathophysiology, and treatment of idiopathic intracranial hypertension were reviewed and interpreted in the context of the authors’ clinical and research experience. Results Idiopathic intracranial hypertension is primarily a disease of obese women of childbearing age, but it can affect patients of any weight, sex, and age. Although a relatively rare disorder, idiopathic intracranial hypertension’s associated costs in the U.S. entail hundreds of millions of dollars. Even following treatment, headaches are frequently persistent and may require the continued involvement of a neurologist. Quality of life reductions and depression are common among idiopathic intracranial hypertension patients. However, visual dysfunction, especially visual field abnormalities, represents the major morbidity of this disorder, and serial automated perimetry remains the primary mode of patient monitoring. Patients who are men, black, very obese, or anemic are at higher risk of visual loss. Vitamin A metabolism, adipose tissue as an actively secreting endocrine tissue, and cerebral venous abnormalities are areas of active study regarding idiopathic intracranial hypertension’s pathophysiology. Treatment studies show that lumbar puncture is a valuable treatment (in addition to its crucial diagnostic role) and that weight management is critical. However, open questions remain regarding the efficacy of acetazolamide, CSF diversion procedures, and cerebral venous stenting. Conclusions Many questions remain unanswered about idiopathic intracranial hypertension. Ongoing studies, especially an ongoing NIH-funded clinical trial of acetazolamide, should provide more insight into this important, yet poorly understood syndrome of isolated intracranial hypertension. PMID:21696699

Comparison between smaller ruptured intracranial aneurysm and larger un-ruptured intracranial aneurysm: gene expression profile analysis.

PubMed

Li, Hao; Li, Haowen; Yue, Haiyan; Wang, Wen; Yu, Lanbing; ShuoWang; Cao, Yong; Zhao, Jizong

2017-07-01

As it grows in size, an intracranial aneurysm (IA) is prone to rupture. In this study, we compared two extreme groups of IAs, ruptured IAs (RIAs) smaller than 10 mm and un-ruptured IAs (UIAs) larger than 10 mm, to investigate the genes involved in the facilitation and prevention of IA rupture. The aneurismal walls of 6 smaller saccular RIAs (size smaller than 10 mm), 6 larger saccular UIAs (size larger than 10 mm) and 12 paired control arteries were obtained during surgery. The transcription profiles of these samples were studied by microarray analysis. RT-qPCR was used to confirm the expression of the genes of interest. In addition, functional group analysis of the differentially expressed genes was performed. Between smaller RIAs and larger UIAs, 101 genes and 179 genes were significantly over-expressed, respectively. In addition, functional group analysis demonstrated that the up-regulated genes in smaller RIAs mainly participated in the cellular response to metal ions and inorganic substances, while most of the up-regulated genes in larger UIAs were involved in inflammation and extracellular matrix (ECM) organization. Moreover, compared with control arteries, inflammation was up-regulated and muscle-related biological processes were down-regulated in both smaller RIAs and larger UIAs. The genes involved in the cellular response to metal ions and inorganic substances may facilitate the rupture of IAs. In addition, the healing process, involving inflammation and ECM organization, may protect IAs from rupture.

Spontaneous intracranial hemorrhage and multiple intracranial aneurysms in a patient with Roberts/SC phocomelia syndrome.

PubMed

Wang, Anthony C; Gemmete, Joseph J; Keegan, Catherine E; Witt, Cordelie E; Muraszko, Karin M; Than, Khoi D; Maher, Cormac O

2011-11-01

Roberts/SC phocomelia syndrome (RBS) is a rare but distinct genetic disorder with an autosomal recessive inheritance pattern. It has been associated with microcephaly, craniofacial malformation, cavernous hemangioma, encephalocele, and hydrocephalus. There are no previously reported cases of RBS with intracranial aneurysms. The authors report on a patient with a history of RBS who presented with a spontaneous posterior fossa hemorrhage. Multiple small intracranial aneurysms were noted on a preoperative CT angiogram. The patient underwent emergency craniotomy for evacuation of the hemorrhage. A postoperative angiogram confirmed the presence of multiple, distal small intracranial aneurysms.

Posterior Circulation Stroke After Bronchial Artery Embolization. A Rare but Serious Complication

DOE Office of Scientific and Technical Information (OSTI.GOV)

Laborda, Alicia; Tejero, Carlos; Fredes, Arturo, E-mail: fredesarturo@gmail.com

Bronchial artery embolization (BAE) is the treatment of choice for massive hemoptysis with rare complications that generally are mild and transient. There are few references in the medical literature with acute cerebral embolization as a complication of BAE. We report a case of intracranial posterior territory infarctions as a complication BAE in a patient with hemoptysis due to bronchiectasis.

Ruptured intracranial aneurysm in patients with osteogenesis imperfecta: 2 familial cases and a systematic review of the literature.

PubMed

Gaberel, T; Rochey, A; di Palma, C; Lucas, F; Touze, E; Emery, E

2016-12-01

Osteogenesis imperfecta is an inherited connective tissue disorder that causes bone fragility. Vascular complications have been described, but only few cases of ruptured intracranial aneurysm have been reported. We first described 2 familial cases of ruptured intracranial aneurysm and then conducted a systematic review of the literature. A mother and her daughter with a typical history of osteogenesis imperfecta presented with subarachnoid hemorrhage, which was related to a posterior communicating artery aneurysm in both cases. The mother had early rebleeding and died. The aneurysm was excluded by coiling in the daughter. Despite occurrence of hydrocephalus and delayed cerebral ischemia, she had an excellent functional outcome. A systematic review of the literature identified seven additional cases. None of the cases were in fact familial. All patients had a previous medical history of multiple fractures. Seven aneurysms were resolved, three by surgical clipping and four by endovascular procedure. No periprocedural complication was reported. One patient died prematurely and 6 experienced good functional outcome. We report the first familial cases of aneurysmal subarachnoid hemorrhage in osteogenesis imperfecta patients. Intracranial aneurysms are probably linked to a collagen pathology, which is at the origin of osteogenesis imperfecta. In cases of aneurysmal subarachnoid hemorrhage in an osteogenesis imperfecta family, intracranial aneurysm screenings in the relatives showing osteogenesis imperfecta should be considered. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Mycotic aneurysm of the popliteal artery due to infective endocarditis.

PubMed

Rajadhyaksha, Anjali; Sonawale, Archana; Rathod, Krantikumar; Khare, Shruti; Kalal, Chetan

2011-10-01

Mycotic aneurysm (MA) is an infrequent complication of infective endocarditis (IE), reported in 3 to 15% of the patients with IE. The commonest site for such aneurysm is intracranial vessels (65%) followed by abdominal and then the peripheral vessels. We describe a case of 32 year old man with recently diagnosed rheumatic heart disease and mitral regurgitation. He had infective endocarditis (IE) and developed a large mycotic popliteal artery aneurysm (MPAA) and a small profunda femoris arterial aneurysm (PFAA) while he was on antibiotic therapy. The patient was successfully treated with prolonged antibiotic therapy and embolisation of the MPAA while PFAA was managed conservatively.

Natural History of Vertebrobasilar Dolichoectatic and Fusiform Aneurysms: A Systematic Review and Meta-Analysis.

PubMed

Nasr, Deena M; Flemming, Kelly D; Lanzino, Giuseppe; Cloft, Harry J; Kallmes, David F; Murad, Mohammad Hassan; Brinjikji, Waleed

2018-01-01

Vertebrobasilar non-saccular and dolichoectatic aneurysms (VBDA) are a rare type of aneurysm and are generally associated with poor prognosis. In order to better characterize the natural history of VBDAs, we performed a systematic review and meta-analysis of the literature to determine rates of mortality, growth, rupture, ischemia, and intraparenchymal hemorrhage. We searched the literature for longitudinal natural history studies of VBDA patients reporting clinical and imaging outcomes. Studied outcomes included annualized rates of growth, rupture, ischemic stroke, intracerebral hemorrhage (ICH), and mortality. We also studied the association between aneurysm morphology (dolichoectatic versus fusiform) and natural history. Meta-analysis was performed using a random-effects model using summary statistics from included studies. Fifteen studies with 827 patients and 5,093 patient-years were included. The overall annual mortality rate among patients with VBDAs was 13%/year (95% CI 8-19). Patients with fusiform aneurysms had a higher mortality rate than those with dolichoectatic aneurysms, but this did not reach statistical significance (12 vs. 8%, p = 0.11). The overall growth rate was 6%/year (95% CI 4-13). Patients with fusiform aneurysms had higher growth rates than those with dolichoectatic aneurysms (12 vs. 3%, p < 0.0001). The overall rupture rate was 3%/year (95% CI 1-5). Patients with fusiform aneurysms had higher rupture rates than those with dolichoectatic aneurysms (3 vs. 0%, p < 0.0001). The overall rate of ischemic stroke was 6%/year (95% CI 4-9). Patients with dolichoectatic aneurysms had higher ischemic stroke rates than those with fusiform aneurysms, but this did not reach statistical significance (8 vs. 4%, p = 0.13). The overall rate of ICH was 2%/year (95% CI 0-8) with no difference in rates between dolichoectatic and fusiform aneurysms (2 vs. 2%, p = 0.65). In general, the natural history of -VBDAs is poor. However, dolichoectatic and fusiform

MRI-based noninvasive measurement of intracranial compliance derived from the relationship between transcranial blood and cerebrospinal fluid flows: modeling vs. direct approach

NASA Astrophysics Data System (ADS)

Tain, Rong-Wen; Alperin, Noam

2008-03-01

Intracranial compliance (ICC) determines the ability of the intracranial space to accommodate increase in volume (e.g., brain swelling) without a large increase in intracranial pressure (ICP). Therefore, measurement of ICC is potentially important for diagnosis and guiding treatment of related neurological problems. Modeling based approach uses an assumed lumped-parameter model of the craniospinal system (CSS) (e.g., RCL circuit), with either the arterial or the net transcranial blood flow (arterial inflow minus venous outflow) as input and the cranio-spinal cerebrospinal fluid (CSF) flow as output. The phase difference between the output and input is then often used as a measure of ICC However, it is not clear whether there is a predetermined relationship between ICC and the phase difference between these waveforms. A different approach for estimation of ICC has been recently proposed. This approach estimates ICC from the ratio of the intracranial volume and pressure changes that occur naturally with each heartbeat. The current study evaluates the sensitivity of the phase-based and the direct approach to changes in ICC. An RLC circuit model of the cranio-spinal system is used to simulate the cranio-spinal CSF flow for 3 different ICC states using the transcranial blood flows measured by MRI phase contrast from healthy human subjects. The effect of the increase in the ICC on the magnitude and phase response is calculated from the system's transfer function. We observed that within the heart rate frequency range, changes in ICC predominantly affected the amplitude of CSF pulsation and less so the phases. The compliance is then obtained for the different ICC states using the direct approach. The measures of compliance calculated using the direct approach demonstrated the highest sensitivity for changes in ICC. This work explains why phase shift based measure of ICC is less sensitive than amplitude based measures such as the direct approach method.

The "focus on aneurysm" principle: Classification and surgical principles of management of concurrent arterial aneurysm with arteriovenous malformation causing intracranial hemorrhage.

PubMed

Jha, Vikas; Behari, Sanjay; Jaiswal, Awadhesh K; Bhaisora, Kamlesh Singh; Shende, Yogesh P; Phadke, Rajendra V

2016-01-01

Concurrent arterial aneurysms (AAs) occurring in 2.7-16.7% patients harboring an arteriovenous malformation (AVM) aggravate the risk of intracranial hemorrhage. We evaluate the variations of aneurysms simultaneously coexisting with AVMs. A classification-based management strategy and an abbreviated nomenclature that describes their radiological features is also proposed. Tertiary care academic institute. Test of significance applied to determine the factors causing rebleeding in the groups of patients with concurrent AVM and aneurysm and those with only AVMs. Sixteen patients (5 with subarachnoid hemorrhage and 11 with intracerebral/intraventricular hemorrhage; 10 with low flow [LF] and 6 with high flow [HF] AVMs) underwent radiological assessment of Spetzler Martin (SM) grading and flow status of AA + AVM. Their modified Rankin's score (mRS) at admission was compared with their follow-up (F/U) score. Pre-operative mRS was 0 in 5, 2 in 6, 3 in 1, 4 in 3 and 5 in 1; and, SM grade I in 5, II in 3, III in 3, IV in 4 and V in 1 patients, respectively. AA associated AVMs were classified as: (I) Flow-related proximal (n = 2); (II) flow-related distal (n = 3); (III) intranidal (n = 5); (IV) extra-intranidal (n = 2); (V) remote major ipsilateral (n = 1); (VI) remote major contralateral (n = 1); (VII) deep perforator related (n = 1); (VIII) superficial (n = 1); and (IX) distal (n = 0). Their treatment strategy included: Flow related AA, SM I-III LF AVM: aneurysm clipping with AVM excision; nidal-extranidal AA, SM I-III LF AVM: Excision or embolization of both AA + AVM; nidal-extranidal and perforator-related AA, SM IV-V HF AVM: Only endovascular embolization or radiosurgery. Surgical decision-making for remote AA took into account their ipsilateral/contralateral filling status and vessel dominance; and, for AA associated with SM III HF AVM, it varied in each patient based on diffuseness of AVM nidus, flow across arteriovenous fistula and eloquence of cortex. Follow up (F

PHACES syndrome: a review of eight previously unreported cases with late arterial occlusions.

PubMed

Bhattacharya, J J; Luo, C B; Alvarez, H; Rodesch, G; Pongpech, S; Lasjaunias, P L

2004-03-01

PHACE and PHACES are acronyms for a syndrome of variable expression comprising posterior cranial fossa malformations, facial haemangiomas, arterial anomalies, aortic coarctation and other cardiac disorders, ocular abnormalities and stenotic arterial disease. We review five girls and three boys aged 1 month-14 years with disorders from this spectrum. Six had large facial haemangiomas but recent reports suggest that small haemangiomas may occur; hence our inclusion of two possible cases. We also focus on the recently recognised feature of progressive intracranial arterial occlusions, present in four of our patients, later than previously recognised, from 4 to 14 years of age. We suggest that many elements of this disorder could reflect an abnormality of cell proliferation and apoptosis.

4D flow MRI assessment of extracranial-intracranial bypass: qualitative and quantitative evaluation of the hemodynamics.

PubMed

Sekine, Tetsuro; Takagi, Ryo; Amano, Yasuo; Murai, Yasuo; Orita, Erika; Matsumura, Yoshio; Kumita, Shin-Ichiro

2016-03-01

Our aim was to assess the feasibility of using time-resolved 3D phase-contrast (4D flow) MRI to characterize extracranial-intracranial (EC-IC) bypass. We enrolled 32 patients who underwent EC-IC bypass (15 men, 17 women; mean age 66.4 years). In all, 16 underwent radial artery graft (RAG) bypass and 16 underwent superficial temporal artery (STA) bypass. 4D flow MRI, time-of-flight (TOF) magnetic resonance angiography (MRA), and computed tomography angiography (CTA) were performed. Bypass patency, flow direction, and blood flow volume (BFV) of each artery were determined by 4D flow MRI. Arterial diameters were measured by TOF-MRA and CTA. We compared RAG and STA bypasses by evaluating the flow direction and BFV of each artery. We evaluated the correlation between arterial diameters (measured by CTA or MRA) and the BFV and the detectability of flow direction (measured by 4D flow MRI) of each artery. 4D flow MRI confirmed the patency of each bypass artery. Flow direction of the M1 segment of the middle cerebral artery and BFV in the bypass artery differed between RAG and STA groups (p < 0.01). BFV in the bypass slightly correlated with the diameters on CTA (p < 0.05, R (2) = 0.287). Of the 29 arteries in the circle of Willis, nine were not depicted on 4D flow MRI. Cutoff values for arterial diameters on CTA and TOF-MRA for detecting the artery on 4D flow MRI were 2.4 and 1.8 mm, respectively. 4D flow MRI provided unique information for characterizing EC-IC bypasses, although this detectability is limited when addressing small arteries with slow flow.

Isolated medial medullary infarction due to vertebral artery dissection.

PubMed

Wakita, M; Matsuoka, H; Hamada, R; Kasuya, J; Osame, M

2003-12-01

A 54-year-old man developed left hemiparesis and tactile and deep sensory disturbance following onset of rightside cervical pain. These symptoms resulted from an isolated infarct in the right medial area of the upper medulla oblongata and intracranial vertebral artery (VA) dissection. Atherosclerotic disease of the VA is the most common cause of medial medullary infarction. In past reports of isolated medial medullary infarction, only a few cases involved VA dissection.

Three-dimensional volume-rendering technique in the angiographic follow-up of intracranial aneurysms embolized with coils.

PubMed

Zhou, Bing; Li, Ming-Hua; Wang, Wu; Xu, Hao-Wen; Cheng, Yong-De; Wang, Jue

2010-03-01

The authors conducted a study to evaluate the advantages of a 3D volume-rendering technique (VRT) in follow-up digital subtraction (DS) angiography of coil-embolized intracranial aneurysms. One hundred nine patients with 121 intracranial aneurysms underwent endovascular coil embolization and at least 1 follow-up DS angiography session at the authors' institution. Two neuroradiologists independently evaluated the conventional 2D DS angiograms, rotational angiograms, and 3D VRT images obtained at the interventional procedures and DS angiography follow-up. If multiple follow-up sessions were performed, the final follow-up was mainly considered. The authors compared the 3 techniques for their ability to detect aneurysm remnants (including aneurysm neck and sac remnants) and parent artery stenosis based on the angiographic follow-up. The Kruskal-Wallis test was used for group comparisons, and the kappa test was used to measure interobserver agreement. Statistical analyses were performed using commercially available software. There was a high statistical significance among 2D DS angiography, rotational angiography, and 3D VRT results (X(2) = 9.9613, p = 0.0069) when detecting an aneurysm remnant. Further comparisons disclosed a statistical significance between 3D VRT and rotational angiography (X(2) = 4.9754, p = 0.0257); a high statistical significance between 3D VRT and 2D DS angiography (X(2) = 8.9169, p = 0.0028); and no significant difference between rotational angiography and 2D DS angiography (X(2) = 0.5648, p = 0.4523). There was no statistical significance among the 3 techniques when detecting parent artery stenosis (X(2) = 2.5164, p = 0.2842). One case, in which parent artery stenosis was diagnosed by 2D DS angiography and rotational angiography, was excluded by 3D VRT following observations of multiple views. The kappa test showed good agreement between the 2 observers. The 3D VRT is more sensitive in detecting aneurysm remnants than 2D DS angiography and

Long-Term Follow-Up for a Giant Basilar Trunk Aneurysm Surgically Treated by Proximal Occlusion and External Carotid Artery to Posterior Cerebral Artery Bypass Using a Saphenous Vein Graft.

PubMed

Yanagisawa, Toshiharu; Kinouchi, Hiroyuki; Sasajima, Toshio; Shimizu, Hiroaki

2016-11-01

The authors describe a case of a basilar trunk aneurysm with long-term follow-up after successful bypass and proximal occlusion. A 64-year-old woman had a giant aneurysm of the basilar trunk and underwent external carotid artery-to-posterior cerebral artery vein graft bypass surgery and proximal clipping of the basilar artery, which was followed by low-dose aspirin (100 mg/d) treatment. No ischemic symptoms and lesions developed and the thrombosed aneurysm was stable during 11 years of follow-up. An extracranial-intracranial high flow bypass combined with immediate proximal occlusion and aspirin administration may be an acceptable treatment option for patients with giant posterior circulation aneurysms. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Geographic and sex difference in the distribution of intracranial atherosclerosis in China.

PubMed

Pu, Yuehua; Liu, Liping; Wang, Yilong; Zou, Xinying; Pan, Yuesong; Soo, Yannie; Leung, Thomas; Zhao, Xingquan; Wong, Ka Sing; Wang, Yongjun

2013-08-01

Geographic variation and sex difference in the distribution of intracranial atherosclerosis (ICAS) have not been fully discussed before in Chinese patients with cerebral ischemia. We performed this study with the aim to investigate geographic and sex difference in the distribution of ICAS in China. In this prospective multicenter study, we evaluated 2864 consecutive patients who experienced an acute cerebral ischemia within 7 days of symptom onset in 22 hospitals in China. All the inclusive patients underwent 3-dimensional time-of-flight MR angiography and duplex color Doppler ultrasound or contrast-enhanced MR angiography to document the presence of intracranial or extracranial stenosis. Intracranial large-artery atherosclerosis was defined as ≥50% diameter reduction on MR angiography. The proportion of patients with ICAS was significantly higher in north China than in south China (50.22% versus 41.88%; P<0.0001). Patients in the north were likely to consume more alcohol and smoke more cigarettes and had significantly higher proportion of diabetes mellitus, family history of stroke, history of cerebral ischemia, heart disease, and higher body mass index. In patients aged >63 years, the percentage of ICAS in women was notably higher than in men (51.51% versus 45.40%; P=0.028). In elderly patients, women had higher proportion of diabetes mellitus, hypertension, hyperlipidemia, and heart disease than men. There exists geographic and sex difference in the distribution of symptomatic ICAS in China. Public health measures should strengthen improving social determinants of health and risk factor prevention/control in high-risk populations for decreasing stroke risk.

Advanced pediatric mastoiditis with and without intracranial complications.

PubMed

Zevallos, Jose P; Vrabec, Jeffrey T; Williamson, Robert A; Giannoni, Carla; Larrier, Deidre; Sulek, Marcelle; Friedman, Ellen M; Oghalai, John S

2009-08-01

Recently, several groups have noticed an increase in cases of advanced pediatric mastoiditis and intracranial complications. The objective of this study was to review the bacteriology of advanced mastoiditis in pediatric patients, with the hypothesis that a difference in bacteriology might explain the development of an intracranial complication. Retrospective chart review. All pediatric patients with coalescent mastoiditis requiring surgery treated at a tertiary care children's hospital between 2002 and 2007 were reviewed. Every patient included was treated either with mastoidectomy alone (for coalescent mastoiditis without an intracranial complication) or with transtemporal craniotomy (for coalescent mastoiditis with an intracranial complication). All patients had surgical specimens sent for pathology, Gram stain, and aerobic and anaerobic cultures. One hundred eight pediatric patients with coalescent mastoiditis were identified: 58 (53%) presented with coalescent mastoiditis alone, 17 (16%) presented with coalescent mastoiditis and an intracranial complication, and 33 (31%) were excluded because they were treated with myringotomy and tubes alone, had incomplete data, or had an unclear diagnosis. Streptococcus pneumoniae was the most commonly cultured organism in patients with and without intracranial complications. Anaerobic isolates were present in 29.4% of patients with intracranial complications and 5.7% of patients without intracranial complications (P = .015). Nearly a quarter of pediatric patients with coalescent mastoiditis presented with a simultaneous intracranial complication. There was an increased incidence of anaerobic organisms in patients with intracranial complications compared to those without, indicating the importance of culture and antibiotic coverage appropriate for anaerobes. This series demonstrates the role of aggressive surgical management and close collaboration with the infectious disease service for long-term intravenous antibiotic

[Non-contrast time-resolved magnetic resonance angiography combining high resolution multiple phase echo planar imaging based signal targeting and alternating radiofrequency contrast inherent inflow enhanced multi phase angiography combining spatial resolution echo planar imaging based signal targeting and alternating radiofrequency in intracranial arteries].

PubMed

Nakamura, Masanobu; Yoneyama, Masami; Tabuchi, Takashi; Takemura, Atsushi; Obara, Makoto; Sawano, Seishi

2012-01-01

Detailed information on anatomy and hemodynamics in cerebrovascular disorders such as AVM and Moyamoya disease is mandatory for defined diagnosis and treatment planning. Arterial spin labeling technique has come to be applied to magnetic resonance angiography (MRA) and perfusion imaging in recent years. However, those non-contrast techniques are mostly limited to single frame images. Recently we have proposed a non-contrast time-resolved MRA technique termed contrast inherent inflow enhanced multi phase angiography combining spatial resolution echo planar imaging based signal targeting and alternating radiofrequency (CINEMA-STAR). CINEMA-STAR can extract the blood flow in the major intracranial arteries at an interval of 70 ms and thus permits us to observe vascular construction in full by preparing MIP images of axial acquisitions with high spatial resolution. This preliminary study demonstrates the usefulness of the CINEMA-STAR technique in evaluating the cerebral vasculature.

Effect of Hemodynamics on Stroke Risk in Symptomatic Atherosclerotic Vertebrobasilar Occlusive Disease.

PubMed

Amin-Hanjani, Sepideh; Pandey, Dilip K; Rose-Finnell, Linda; Du, Xinjian; Richardson, DeJuran; Thulborn, Keith R; Elkind, Mitchell S V; Zipfel, Gregory J; Liebeskind, David S; Silver, Frank L; Kasner, Scott E; Aletich, Victor A; Caplan, Louis R; Derdeyn, Colin P; Gorelick, Philip B; Charbel, Fady T

2016-02-01

Atherosclerotic vertebrobasilar (VB) occlusive disease is a significant etiology of posterior circulation stroke, with regional hypoperfusion as an important potential contributor to stroke risk. To test the hypothesis that, among patients with symptomatic VB stenosis or occlusion, those with distal blood flow compromise as measured by large-vessel quantitative magnetic resonance angiography (QMRA) are at higher risk of subsequent posterior circulation stroke. A prospective, blinded, longitudinal cohort study was conducted at 5 academic hospital-based centers in the United States and Canada; 82 patients from inpatient and outpatient settings were enrolled. Participants with recent VB transient ischemic attack or stroke and 50% or more atherosclerotic stenosis or occlusion in vertebral and/or basilar arteries underwent large-vessel flow measurement in the VB territory using QMRA. Physicians performing follow-up assessments were blinded to QMRA flow status. Follow-up included monthly telephone calls for 12 months and biannual clinical visits (for a minimum of 12 months, and up to 24 months or the final visit). Enrollment took place from July 1, 2008, to July 31, 2013, with study completion on June 30, 2014; data analysis was performed from October 1, 2014, to April 10, 2015. Standard medical management of stroke risk factors. The primary outcome was VB-territory stroke. Of the 82 enrolled patients, 72 remained eligible after central review of their angiograms. Sixty-nine of 72 patients completed the minimum 12-month follow-up; median follow-up was 23 (interquartile range, 14-25) months. Distal flow status was low in 18 of the 72 participants (25%) included in the analysis and was significantly associated with risk for a subsequent VB stroke (P = .04), with 12- and 24-month event-free survival rates of 78% and 70%, respectively, in the low-flow group vs 96% and 87%, respectively, in the normal-flow group. The hazard ratio, adjusted for age and stroke risk factors

[Hypothermia for intracranial hypertension].

PubMed

Bruder, N; Velly, L; Codaccioni, J-L

2009-04-01

There is a large body of experimental evidence showing benefits of deliberate mild hypothermia (33-35 degrees C) on the injured brain as well as an improvement of neurological outcome after cardiac arrest in humans. However, the clinical evidence of any benefit of hypothermia following stroke, brain trauma and neonatal asphyxia is still lacking. Controversial results have been published in patients with brain trauma or neonatal asphyxia. Hypothermia can reduce the elevation of intracranial pressure, through mechanisms not completely understood. Hypothermia-induced hypocapnia should have a role on the reduction of intracranial pressure. The temperature target is unknown but no additional benefit was found below 34 degrees C. The duration of deliberate hypothermia for the treatment of elevated intracranial pressure might be at least 48 hours, and the subsequent rewarming period must be very slow to prevent adverse effects.

Multiple intracranial aneurysms and moyamoya disease associated with microcephalic osteodysplastic primordial dwarfism type II: surgical considerations.

PubMed

Waldron, James S; Hetts, Steven W; Armstrong-Wells, Jennifer; Dowd, Christopher F; Fullerton, Heather J; Gupta, Nalin; Lawton, Michael T

2009-11-01

Microcephalic osteodysplastic primordial dwarfism type II (MOPD II) is a rare genetic syndrome characterized by extremely small stature and microcephaly, and is associated in 25% of patients with intracranial aneurysms and moyamoya disease. Although aneurysmal subarachnoid hemorrhage and stroke are leading causes of morbidity and death in these patients, MOPD II is rarely examined in the neurosurgical literature. The authors report their experience with 3 patients who presented with MOPD II, which includes a patient with 8 aneurysms (the most aneurysms reported in the literature), and the first report of a patient with both moyamoya disease and multiple aneurysms. The poor natural history of these lesions indicates aggressive microsurgical and/or endovascular therapy. Microsurgery, whether for aneurysm clip placement or extracranial-intracranial bypass, is challenging due to tight surgical corridors and diminutive arteries in these patients, but is technically feasible and strongly indicated when multiple aneurysms must be treated or cerebral revascularization is needed.

Safety and efficacy of combined epidural/general anesthesia during major abdominal surgery in patients with increased intracranial pressure: a cohort study.

PubMed

Zabolotskikh, Igor; Trembach, Nikita

2015-05-15

The increased intracranial pressure can significantly complicate the perioperative period in major abdominal surgery, increasing the risk of complications, the length of recovery from the surgery, worsening the outcome. Epidural anesthesia has become a routine component of abdominal surgery, but its use in patients with increased intracranial pressure remains controversial. The goal of the study was to evaluate the safety and efficacy of epidural anesthesia, according to monitoring of intracranial pressure in patients with increased intracranial pressure. The study includes 65 surgical patients who were routinely undergone the major abdominal surgery under combined epidural/general anesthesia. Depending on the initial ICP all patients were divided into 2 groups: 1 (N group) - patients with the normal intracranial pressure (≤12 mm Hg, n = 35) and 2 (E group) - patients with the elevated intracranial pressure (ICP > 12 mm Hg, n = 30). During the surgery we evaluated ICP, blood pressure, cerebral perfusion pressure (CPP). The parameters of recovery from anesthesia and the effectiveness of postoperative analgesia were also assessed. In N group ICP remained stable. In E group ICP decreased during anesthesia, the overall decline was 40% at the end of the operation (from 15 to 9 mm Hg (P <0.05)). The correction of MAP with vasopressors to maintain normal CPP was required mainly in patients with increased ICP (70% vs. 45%, p <0.05). CPP declined by 19% in N group. In E group the CPP reduction was 23%, and then it remained stable at 60 mm Hg. No significant differences in time of the recovery of consciousness, effectiveness of postoperative analgesia and complications between patients with initially normal levels of ICP and patients with ICH were noted. The combination of general and epidural anesthesia is safe and effective in patients with increased intracranial pressure undergoing elective abdominal surgery under the condition of maintaining the arterial

The arteries of brain base in species of Bovini tribe.

PubMed

Zdun, Maciej; Frąckowiak, Hieronim; Kiełtyka-Kurc, Agata; Kowalczyk, Karolina; Nabzdyk, Maria; Timm, Anita

2013-11-01

Studies were conducted on 78 preparations of head and brain arteries in four species of Bos genus, that is in domestic cattle (N = 59), including 22 foetuses (CRL 36.5-78.5 cm), in banteng (Bos javanicus, N = 3), yak (Bos mutus f. grunniens, N = 2), American bison (Bison bison, N = 4), and European bison (Bison bonasus, N = 10). The comparative analysis permitted to demonstrate a similar pattern of brain base arteries in the studied animals. In the studied species, blood vessels of the arterial circle of the brain were found to form by bifurcation of intracranial segments of inner carotid arteries, which protruded from the paired rostral epidural rete mirabile. In Bovidae arterial circle of the brain was supplied with blood mainly by maxillary artery through the blood vessels of the paired rostral epidural rete mirabile. The unpaired caudal epidural rete mirabile was participating in blood supply to the arterial circle of the brain from vertebral and occipital arteries. It manifested character of a taxonomic trait for species of Bos and Bison genera. Basilar artery in all the examined animals manifested a variable diameter, with preliminary portion markedly narrowed, which prevented its participation in blood supply to the arterial circle of the brain. The results and taxonomic position of the species made the authors to suggest a hypothesis that a similar arterial pattern on the brain base might be present also in other species, not included in this analysis. Copyright © 2013 Wiley Periodicals, Inc.

Can intracranial pressure be measured non-invasively bedside using a two-depth Doppler-technique?

PubMed

Koskinen, Lars-Owe D; Malm, Jan; Zakelis, Rolandas; Bartusis, Laimonas; Ragauskas, Arminas; Eklund, Anders

2017-04-01

Measurement of intracranial pressure (ICP) is necessary in many neurological and neurosurgical diseases. To avoid lumbar puncture or intracranial ICP probes, non-invasive ICP techniques are becoming popular. A recently developed technology uses two-depth Doppler to compare arterial pulsations in the intra- and extra-cranial segments of the ophthalmic artery for non-invasive estimation of ICP. The aim of this study was to investigate how well non-invasively-measured ICP and invasively-measured cerebrospinal fluid (CSF) pressure correlate. We performed multiple measurements over a wide ICP span in eighteen elderly patients with communicating hydrocephalus. As a reference, an automatic CSF infusion apparatus was connected to the lumbar space. Ringer's solution was used to create elevation to pre-defined ICP levels. Bench tests of the infusion apparatus showed a random error (95 % CI) of less than ±0.9 mmHg and a systematic error of less than ±0.5 mmHg. Reliable Doppler signals were obtained in 13 (72 %) patients. An infusion test could not be performed in one patient. Thus, twelve patients and a total of 61 paired data points were studied. The correlation between invasive and non-invasive ICP measurements was good (R = 0.74), and the 95 % limits of agreements were -1.4 ± 8.8 mmHg. The within-patient correlation varied between 0.47 and 1.00. This non-invasive technique is promising, and these results encourage further development and evaluation before the method can be recommended for use in clinical practice.

Reverse waffle cone technique in management of stent dislodgement into intracranial aneurysms.

PubMed

Luo, Chao-Bao; Lai, Yen-Jun; Teng, Michael Mu-Huo; Chang, Feng-Chi; Lin, Chung-Jung; Guo, Wan-Yuo

2013-09-01

Stent-assisted coil embolization (SACE) is a common method to manage intracranial wide-neck aneurysm. Using this technique, a stent must be successfully deployed into the parent artery to cross the aneurysm neck. We describe the reverse waffle cone technique in management of intra-procedural stent dislodgement during SACE of internal carotid artery (ICA) wide-neck aneurysms. Two patients with unruptured wide-neck ICA aneurysms underwent SACE. Intra-procedural forward stent migration occurred during catheterization with proximal stent dislodgement and migration into the aneurysm sac. Navigation of a second stent to bridge the aneurysm neck failed in one patient because the second stent was impeded by the dislodged stent. Using the reverse waffle cone technique, a microcatheter was navigated into the aneurysm sacs. Coils were safely detached into each aneurysm sac without any device assistance. The two wide-neck aneurysms were successfully treated with preservation of flow to the internal carotid arteries. The complication of intra-procedural distal stent migration and dislodgement, with proximal stent prolapse into an aneurysm sac, may not result in a failure to coil the aneurysm. The reverse waffle cone technique provides an effective treatment in the management of this complication. Copyright © 2013 Elsevier Ltd. All rights reserved.

Flow Diversion for Treatment of Growing A2 Aneurysm in a Child: Case Report and Review of Flow Diversion for Intracranial Aneurysms in Pediatric Patients.

PubMed

Vachhani, Jay Ashok; Nickele, Christopher Michael; Elijovich, Lucas; Klimo, Paul; Arthur, Adam Stephen

2016-12-01

Intracranial flow diversion has gained increasing popularity since the approval of the Pipeline Embolization Device (PED). Although it is only approved for use in adult patients, the PED has been used to treat aneurysms in pediatric patients. We present the first reported case of the use of a PED in a pediatric patient to treat an unusual fusiform distal anterior cerebral artery aneurysm. A 12-year-old girl presented with new onset seizures and was found to have a distal left anterior cerebral artery aneurysm. Initially, this was managed conservatively, but follow-up imaging performed 4 months after presentation demonstrated enlargement of the aneurysm. The patient underwent endovascular embolization of her aneurysm with PED. This was successfully performed and the patient recovered from the procedure with no neurologic deficits. Follow-up digital subtraction angiography and magnetic resonance angiography at 6 and 12 months, respectively, showed complete occlusion of the aneurysm. We also reviewed the literature on flow diversion for treatment of pediatric intracranial aneurysms. Copyright © 2016 Elsevier Inc. All rights reserved.

Morphological Variables Associated With Ruptured Middle Cerebral Artery Aneurysms.

PubMed

Zhang, Jian; Can, Anil; Mukundan, Srinivasan; Steigner, Michael; Castro, Victor M; Dligach, Dmitriy; Finan, Sean; Yu, Sheng; Gainer, Vivian; Shadick, Nancy A; Savova, Guergana; Murphy, Shawn; Cai, Tianxi; Wang, Zhong; Weiss, Scott T; Du, Rose

2018-05-30

Geometric factors of intracranial aneurysms and surrounding vasculature could affect the risk of aneurysm rupture. However, large-scale assessments of morphological parameters correlated with intracranial aneurysm rupture in a location-specific manner are scarce. To investigate the morphological characteristics associated with ruptured middle cerebral artery (MCA) aneurysms. Five hundred sixty-one patients with 638 MCA aneurysms diagnosed between 1990 and 2016 who had available computed tomography angiography (CTA) were included in this study. CTAs were evaluated using the Vitrea Advanced Visualization software for 3-dimensional (3D) reconstruction. Morphological parameters examined in each model included aneurysm projection, wall irregularity, presence of a daughter dome, presence of hypoplastic or aplastic A1 arteries and hypoplastic or fetal posterior communicating arteries (PCoA), aneurysm height and width, neck diameter, bottleneck factor, aspect and size ratio, height/width ratio, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine the association of morphological characteristics with rupture of MCA aneurysms. Logistic regression was used to build a predictive MCA score. Greater bottleneck and size ratio, and irregular, multilobed, temporally projecting MCA aneurysms are associated with higher rupture risk, whereas higher M1/M2 ratio, larger width, and the presence of an ipsilateral or bilateral hypoplastic PCoA were inversely associated with rupture. The MCA score had good predictive capacity with area under the receiver operating curve = 0.88. These practical morphological parameters specific to MCA aneurysms are easy to assess when examining 3D reconstructions of unruptured aneurysms and could aid in risk evaluation in these patients.

Treatment Strategies for Intracranial Mirror Aneurysms.

PubMed

Wang, Wen-Xin; Xue, Zhe; Li, Lin; Wu, Chen; Zhang, Yan-Yang; Lou, Xin; Ma, Lin; Sun, Zheng-Hui

2017-04-01

Intracranial mirror aneurysms are clinically rare and uncommonly reported in the literature. Therefore, the present study evaluated a series of mirror aneurysm cases with respect to the clinical features of the patients and the treatment strategies that were used. This study retrospectively reviewed and systematically analyzed the clinical features, imaging data, treatment methods, and treatment outcomes of 68 cases of mirror aneurysms (a total of 70 pairs) in patients who were admitted to our department between November 2007 and May 2016. The patient population included 24 male and 44 female patients, with a mean age of 52 years. The mirror aneurysms were primarily located in posterior communicating artery and middle cerebral artery and 65 of the aneurysms were large or giant (≧10 mm). Of the 68 patients, 28 were treated by the clipping or embolization of all aneurysms in one stage, 16 were treated in 2 stages, 16 were treated by treating part of the aneurysms, and 8 were observed. The modified Rankin Scale scores of the 60 patients that were treated indicated that 52 had a good recovery (modified Rankin Scale score ≦2; 86.7%), and 1 patient died. Treatment strategies for mirror aneurysms should be determined individually according to the location, size, and morphology of the aneurysm, as well as the clinical manifestations of each patient. Furthermore, the responsible ruptured aneurysm should be given treatment priority, whereas the contralateral unruptured aneurysm should be observed or treated in either 1 or 2 stages. Copyright © 2017 Elsevier Inc. All rights reserved.

Reconfigurable Polymer Networks for Improved Treatment of Intracranial Aneurysms

NASA Astrophysics Data System (ADS)

Ninh, Chi Suze Q.

Endovascular embolization of intracranial aneurysms is a minimally invasive treatment in which an implanted material forms a clot to isolate the weakened vessel. Current strategy suffers from long-term potential failure modes. These potential failure modes include (1) enzymatic degradation of the fibrin clot that leads to compaction of the embolic agent, (2) incomplete filling of the aneurysm sac by embolic agent, and (3) challenging geometry of wide neck aneurysms. In the case of wide neck aneurysms, usually an assisting metal stent is used to help open the artery. However, metal stents with much higher modulus in comparison to the soft blood vessel can cause biocompatibilities issues in the long term such as infection and scarring. Motivated to solve these challenges associated with endovascular embolization, strategies to synthesize and engineer reconfigurable and biodegradable polymers as alternative therapies are evaluated in this thesis. (1) Reconfiguration of fibrin gel's modulus was achieved through crosslinking with genipin released from a biodegradable polymer matrix. (2) Reconfigurability can also be achieved by transforming triblock co-polymer hydrogel into photoresponsive material through incorporation of melanin nanoparticles as efficient photosensitizers. (3) Finally, reconfigurability can be conferred on biodegradable polyester networks via Diels-Alder coupling of furan pendant groups and dimaleimide crosslinking agent. Taken all together, this thesis describes strategies to transform a broad class of polymer networks into reconfigurable materials for improved treatment of intracranial aneurysms as well as for other biomedical applications.

Indocyanine green videoangiography "in negative": definition and usefulness in intracranial dural arteriovenous fistulae.

PubMed

Simal Julián, Juan Antonio; Miranda Lloret, Pablo; Aparici Robles, Fernando; Beltrán Giner, Andrés; Botella Asunción, Carlos

2013-09-01

Indocyanine green videoangiography (IGV) raises important limitations when we use it in vascular pathology, especially in cases with arterialization of the venous system such as arteriovenous malformations and fistulae. Our objective was to provide a simple procedure that overcomes the limitations of conventional IGV. We define IGV in negative (IGV-IN), so-called because, in its first phase, the vessel to analyze is clipped, and we report 3 cases of intracranial dural arteriovenous fistulae treated with this procedure. In 2011, we applied IGV-IN to 3 patients at our center with Borden type III intracranial arteriovenous fistulae. In all 3 cases, IGV-IN enabled both diagnosis and post-dural arteriovenous fistula exclusion control in 1 integrated procedure no longer than 1 minute, requiring only 1 visualization. IGV-IN is an improvement over the conventional IGV method and is able to provide more information in a shorter period of time. It is an intuitive and highly visual procedure, and, more importantly, it is reversible. Studies with larger samples are necessary to determine whether IGV-IN can further reduce the need for postoperative digital subtraction angiography.

Solving the Issue of Restenosis After Stenting of Intracranial Stenoses: Experience with Two Thin-Strut Drug-Eluting Stents (DES)—Taxus Element™ and Resolute Integrity™

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kurre, Wiebke, E-mail: wiebke.kurre@gmx.de; Aguilar-Pérez, Marta; Fischer, Sebastian

PurposeThin-strut, flexible DES are suitable for intracranial stenting and may improve long-term vessel patency. The purpose of this study was to report our experience with two new-generation DES for the treatment of intracranial atherosclerotic disease.Patients and MethodsWe retrospectively reviewed all patients treated with Taxus Element™ or Resolute Integrity™ stent for an intracranial atherosclerotic stenosis between March 2011 and August 2013. Technical success was defined as the ability to deploy the device at the desired location and reduce the degree of stenosis below 50 %. All procedure-related strokes were recorded. Control angiography was scheduled after 6 weeks, 3, 6, and 12 months and yearlymore » thereafter. A luminal narrowing ≥50 % was regarded as a restenosis. Stroke recurrence in the territory of the treated artery was reported.ResultsIn the defined period we treated 101 patients harboring 117 intracranial stenoses. The procedure was successful in 100 (85.5 %) lesions. Procedure-related strokes occurred in 10 (9.9 %) patients with a permanent morbidity in 3 (3.0 %). Follow-up angiography was available for 83 of 100 (83.0 %) successfully treated lesions with an average of 355 days (IQR 153–482 days). Three (3.6 %) asymptomatic restenoses were detected. All occurred after treatment with Resolute Integrity™, none after Taxus Element™ (p = 0.059). New strokes in the territory of the treated artery were encountered in 2 (2.6 %) occasions.ConclusionThin-strut DES improve long-term patency and reduce the risk of subsequent stroke. Differences between devices may exist. Feasibility is comparable to bare-metal balloon-mounted stents and procedure-related strokes occurred within the expected range.« less

Microoptomechanical sensor for intracranial pressure monitoring

NASA Astrophysics Data System (ADS)

Andreeva, A. V.; Luchinin, V. V.; Lutetskiy, N. A.; Sergushichev, A. N.

2014-12-01

The main idea of this research is the development of microoptomechanical sensor for intracranial pressure monitoring. Currently, the authors studied the scientific and technical knowledge in this field, as well as develop and test a prototype of microoptomechanical sensor for intracranial pressure (ICP) monitoring.

Flow Instability and Wall Shear Stress Ocillation in Intracranial Aneurysms

NASA Astrophysics Data System (ADS)

Baek, Hyoungsu; Jayamaran, Mahesh; Richardson, Peter; Karniadakis, George

2009-11-01

We investigate the flow dynamics and oscillatory behavior of wall shear stress (WSS) vectors in intracranial aneurysms using high-order spectral/hp simulations. We analyze four patient- specific internal carotid arteries laden with aneurysms of different characteristics : a wide-necked saccular aneurysm, a hemisphere-shaped aneurysm, a narrower-necked saccular aneurysm, and a case with two adjacent saccular aneurysms. Simulations show that the pulsatile flow in aneurysms may be subject to a hydrodynamic instability during the decelerating systolic phase resulting in a high-frequency oscillation in the range of 30-50 Hz. When the aneurysmal flow becomes unstable, both the magnitude and the directions of WSS vectors fluctuate. In particular, the WSS vectors around the flow impingement region exhibit significant spatial and temporal changes in direction as well as in magnitude.

Lack of effect of moderate hypothermia on brain tissue oxygenation after acute intracranial hypertension in pigs.

PubMed

Bao, Ying-Hui; Liang, Yu-Min; Gao, Guo-Yi; Jiang, Ji-Yao

2010-02-01

In this study, we explored the effect of moderate hypothermia on brain tissue oxygenation following acute intracranial hypertension in micropigs. Twenty healthy juvenile micropigs weighting 4-6 kg were randomized into two groups: a normothermia group (n = 10) and a moderate hypothermia group (n = 10). The animals were intravenously anesthetized with propofol (4 mg/kg), an endotracheal tube was inserted, and mechanical ventilation was begun. Autologous arterial blood was injected into the left frontal lobe to establish acute intracerebral hematoma and intracranial hypertension (intracranial pressure [ICP] >40 mm Hg) in all animals. Cooling was initiated at 30 min after injection of the blood, and was achieved via the use of an ice bath and ice packs. In the hypothermia group, the brain temperature decreased to 33-34 degrees C. Brain temperature was maintained at 37 +/- 0.3 degrees C in the normothermia group. The ICP, cerebral perfusion pressure (CPP), brain tissue oxygen pressure (P(br)O(2)), brain tissue carbon dioxide pressure (P(br)CO(2)), and brain tissue pH value (pH(br)) were continuously monitored for 3 h in all animals. Compared to normothermia group, ICP values significantly decreased and CPP markedly improved in the hypothermia group (p < 0.05). Further, pH(br) also markedly increased and P(br)CO(2) decreased significantly in the hypothermia group (p < 0.05). However, P(br)O(2) did not statistically significantly improve in the hypothermia group (p > 0.05). In sum, moderate hypothermia significantly decreased ICP, reduced P(br)CO(2), and increased pH(br) values, but did not improve cerebral oxygenation following acute intracranial hypertension.

Contrast-enhanced time-resolved MRA for follow-up of intracranial aneurysms treated with the pipeline embolization device.

PubMed

Boddu, S R; Tong, F C; Dehkharghani, S; Dion, J E; Saindane, A M

2014-01-01

Endovascular reconstruction and flow diversion by using the Pipeline Embolization Device is an effective treatment for complex cerebral aneurysms. Accurate noninvasive alternatives to DSA for follow-up after Pipeline Embolization Device treatment are desirable. This study evaluated the accuracy of contrast-enhanced time-resolved MRA for this purpose, hypothesizing that contrast-enhanced time-resolved MRA will be comparable with DSA and superior to 3D-TOF MRA. During a 24-month period, 37 Pipeline Embolization Device-treated intracranial aneurysms in 26 patients underwent initial follow-up by using 3D-TOF MRA, contrast-enhanced time-resolved MRA, and DSA. MRA was performed on a 1.5T unit by using 3D-TOF and time-resolved imaging of contrast kinetics. All patients underwent DSA a median of 0 days (range, 0-68) after MRA. Studies were evaluated for aneurysm occlusion, quality of visualization of the reconstructed artery, and measurable luminal diameter of the Pipeline Embolization Device, with DSA used as the reference standard. The sensitivity, specificity, and positive and negative predictive values of contrast-enhanced time-resolved MRA relative to DSA for posttreatment aneurysm occlusion were 96%, 85%, 92%, and 92%. Contrast-enhanced time-resolved MRA demonstrated superior quality of visualization (P = .0001) and a higher measurable luminal diameter (P = .0001) of the reconstructed artery compared with 3D-TOF MRA but no significant difference compared with DSA. Contrast-enhanced time-resolved MRA underestimated the luminal diameter of the reconstructed artery by 0.965 ± 0.497 mm (27% ± 13%) relative to DSA. Contrast-enhanced time-resolved MRA is a reliable noninvasive method for monitoring intracranial aneurysms following flow diversion and vessel reconstruction by using the Pipeline Embolization Device. © 2014 by American Journal of Neuroradiology.

Improved black-blood imaging using DANTE-SPACE for simultaneous carotid and intracranial vessel wall evaluation.

PubMed

Xie, Yibin; Yang, Qi; Xie, Guoxi; Pang, Jianing; Fan, Zhaoyang; Li, Debiao

2016-06-01

The purpose of this study was to develop a three-dimensional black blood imaging method for simultaneously evaluating the carotid and intracranial arterial vessel walls with high spatial resolution and excellent blood suppression with and without contrast enhancement. The delay alternating with nutation for tailored excitation (DANTE) preparation module was incorporated into three-dimensional variable flip angle turbo spin echo (SPACE) sequence to improve blood signal suppression. Simulations and phantom studies were performed to quantify image contrast variations induced by DANTE. DANTE-SPACE, SPACE, and two-dimensional turbo spin echo were compared for apparent signal-to-noise ratio, contrast-to-noise ratio, and morphometric measurements in 14 healthy subjects. Preliminary clinical validation was performed in six symptomatic patients. Apparent residual luminal blood was observed in five (pre-contrast) and nine (post-contrast) subjects with SPACE and only two (post-contrast) subjects with DANTE-SPACE. DANTE-SPACE showed 31% (pre-contrast) and 100% (post-contrast) improvement in wall-to-blood contrast-to-noise ratio over SPACE. Vessel wall area measured from SPACE was significantly larger than that from DANTE-SPACE due to possible residual blood signal contamination. DANTE-SPACE showed the potential to detect vessel wall dissection and identify plaque components in patients. DANTE-SPACE significantly improved arterial and venous blood suppression compared with SPACE. Simultaneous high-resolution carotid and intracranial vessel wall imaging to potentially identify plaque components was feasible with a scan time under 6 min. Magn Reson Med 75:2286-2294, 2016. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.

Mechanical Removal of Migrated Onyx Due to Microcatheter Rupture During AVM Embolization: A Technical Case Report.

PubMed

Senturk, Cagin

2015-12-01

We report a case where migrated Onyx could be removed safely with a mechanical thrombectomy device after withdrawal of the damaged microcatheter. A microcatheter was retained in the superior cerebellar artery with attached Onyx fragments on its tip during embolization of a bled cerebellar AVM. During retrieval maneuvers microcatheter shaft was ruptured and Onyx fragments were released into the vertebrobasilar system causing occlusion. Finally, Onyx fragment on tip of the microcatheter could be detached with dimethyl sulfoxide injection and the microcatheter could be withdrawn. A Merci retriever device (Concentric Medical, Mountain View, CA, USA) was successfully used to retrieve most of the dislodged Onyx material and recanalize the vertebrobasilar circulation.

Stent-Assisted Coil Embolization of a Mycotic Renal Artery Aneurysm by Use of a Self-Expanding Neurointerventional Stent

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rabellino, Martin, E-mail: jmrabellino@hotmail.com; Garcia-Nielsen, Luis, E-mail: luisgarcia@hospiten.es; Zander, Tobias, E-mail: tobiaszander@hospiten.es

2011-02-15

Mycotic aneurysms are uncommon, especially those located in visceral arteries. We present a case of a patient with two visceral mycotic aneurysms due to bacterial endocarditis, one located in right upper pole renal artery and the second in the splenic artery. Both aneurysms were treated as endovascular embolization using microcoils. In the aneurysm located at the renal artery, the technique of stent-assisted coils embolization was preferred to avoid coils migration due to its wide neck. The stent used was the Solitaire AB, which was designed for the treatment of intracranial aneurysms and was used recently in acute stroke as amore » mechanical thrombectomy device. Complete embolization of the aneurysm was achieved, preserving all the arterial branches without nephrogram defects in the final angiogram.« less

Cervical vertigo and dizziness after whiplash injury.

PubMed

Endo, Kenji; Ichimaru, Katsuji; Komagata, Mashashi; Yamamoto, Kengo

2006-06-01

Whiplash injury is not only limited to neck injury but also brainstem injury that does not involve direct damage to the neck or head. The symptoms of whiplash injury are polymorphous, with the most common complaints being cervical pain, headache and scapulodynia. Vertigo and dizziness are also reported in 25-50% of the cases. In otoneurologic studies, magnetic resonance angiography (MRA) is used for the evaluation of vertebrobasilar hemodynamics in patients who complain of dizziness and vertigo. It is reported that vertebrobasilar artery insufficiency (VBI) leads to brainstem and cerebellar ischemia and infarction following cervical manipulation. Here we examined the correlation between vertigo or dizziness and the right and left side difference in vertebral arteries after whiplash injury using MRA. We studied 20 patients who complained of neck pain with vertigo or dizziness after whiplash injury and 13 healthy volunteers as a control. In the control group, abnormal MRA findings in the vertebral arteries such as occlusion, stenosis or slow blood flow were seen in 77% of the cases. In the patient group, abnormal MRA findings were seen in 60%. The side difference in blood flow was 3.5+/-2.5 cm/s in the control group and 6.1+/-3.0 cm/s in the patient group. Our findings suggest that some subjects with persistent vertigo or dizziness after whiplash injury are more likely to have VBI on MRA. VBI might be an important background factor to evoke cervical vertigo or dizziness after whiplash injury. The side difference between the two vertebral arteries could cause a circulation disorder in the vertebrobasilar system after whiplash injury. However, the VBI on MRA itself was also seen in the control group, and thus it is not clear whether it is due to whiplash injury in the patient group.

Association of Ring Finger Protein 213 Gene P.R4810k Polymorphism with Intracranial Major Artery Stenosis/Occlusion.

PubMed

Zhang, Qian; Yu, Lebao; Ge, Peicong; Ma, Yonggang; Zhang, Dong; Zhang, Yan; Wang, Rong; Wang, Shuo; Zhao, Yuanli; Cao, Yong; Liu, Xingju; Deng, Xiaofeng; Zhao, Jizong

2018-06-01

Intracranial major artery stenosis/occlusion (ICASO) is a common cause of ischemic stroke worldwide. A number of studies have assessed the association of the p.R4810K polymorphism in the ring finger protein 213 (RNF213) gene with ICASO, but the results have not been entirely consistent. We conducted a case-control study to estimate the association between the p.R4810K polymorphism and the risk of ICASO in a Chinese population. A total of 124 patients and 230 controls were enrolled. Moreover, a meta-analysis was performed to evaluate this association in the East Asian populations. In our case-control study, the frequencies of the G/A genotype of p.R4810K were significantly higher in the ICASO patients than in the control group (4.03% versus .43%, P = .021, respectively). Moreover, in the meta-analysis, we assessed 7 case-control studies that included 1239 patients and 1377 controls. The pooled odds ratios (ORs) indicated significant association between the p.R4810K polymorphism and the ICASO risk in the dominant model (OR = 9.37, 95% confidence interval: 4.61-19.02, P = .000), the heterozygote comparison (OR = 8.97, 95% CI: 4.41-18.25, P = .000), and the allele comparison (OR = 9.50, 95% confidence interval: 4.71-19.19, P = .000) in the East Asian populations. Subgroup analysis based on ethnicity revealed that the risks in the Japanese and the Korean populations were higher than that in the Chinese population. The p.R4810K polymorphism was associated with an increased risk of ICASO in the East Asian populations. Further studies on the function of the RNF213 protein and the clinical features of this subtype of ICASO are needed. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

A randomized trial comparing primary angioplasty versus stent placement for symptomatic intracranial stenosis

PubMed Central

Qureshi, Adnan I; Chaudhry, Saqib A; Siddiq, Farhan; Majidi, Shahram; Rodriguez, Gustavo J; Suri, M Fareed K

2013-01-01

Background: Both primary angioplasty alone and angioplasty with a self-expanding stent have been compared in non-randomized concurrent clinical studies that suggest equivalent results. However, there is no randomized trial that has compared the two procedures in patients with symptomatic high grade intracranial stenosis. Objective: The primary aim of the randomized trial was to compare the clinical and angiographic efficacy of primary angioplasty and angioplasty followed by stent placement in preventing restenosis, stroke, requirement for second treatment, and death in patients with symptomatic intracranial stenosis. Methods: The study prospectively evaluated efficacy and safety of the two existing neurointerventional techniques for treatment of moderate intracranial stenosis (stenosis ≥ 50%) with documented failure of medical treatment or severe stenosis (≥70%) with or without failure of medical treatment. Results: A total of 18 patients were recruited in the study (mean age [±SD] was 64.7 ± 15.1 years); out of these, 12 were men. Of these 18, 10 were treated with primary angioplasty and 8 were treated with angioplasty followed by self-expanding stent. The technical success rates of intracranial angioplasty and stent placements defined as ability to achieve <30% residual stenosis when assessed by immediate post-procedure angiography was 5 of 10 and 5 of 8 patients, respectively. The total fluoroscopic time (mean [±SD]) was lower in patients undergoing primary angioplasty 37 [±11] min versus those undergoing angioplasty followed by self-expanding stent 42 [±15] min, P = 0.4321. The stroke and death rate within 1 month was very low in both patient groups (1 of 10 versus 0 of 8 patients). One patient randomized to stent placement continued to have recurrent ischemic symptoms requiring another angioplasty in the vertebral artery on post-procedure Day 2. Conclusions: The trial suggests that a randomized trial comparing primary angioplasty to angioplasty

Successful Retreatment of Recurrent Intracranial Vertebral Artery Dissecting Aneurysms After Stent-Assisted Coil Embolization: A Self-Controlled Hemodynamic Analysis.

PubMed

Liu, Jian; Jing, Linkai; Zhang, Ying; Song, Ying; Wang, Yang; Li, Chuanhui; Wang, Yanmin; Mu, Shiqing; Paliwal, Nikhil; Meng, Hui; Linfante, Italo; Yang, Xinjian

2017-01-01

Intracranial vertebral artery dissecting aneurysms (VADAs) tend to recur despite successful stent-assisted coil embolization (SACE). Hemodynamics is useful in evaluating aneurysmal formation, growth, and rupture. Our aim was to evaluate the hemodynamic patterns of the recurrence of VADA. Between September 2009 and November 2013, all consecutive patients with recurrent VADAs after SACE in our institutions were enrolled. Recurrence was defined as recanalization and/or regrowth. We assessed the hemodynamic alterations in wall shear stress (WSS) and velocity after the initial SACE and subsequently after retreatment of the aneurysms that recurred. Five patients were included. After the initial treatment, 3 patients showed recanalization and 2 showed regrowth. In the 2 patients with regrowth, the 2 original aneurysms maintained complete occlusion; however, de novo aneurysm regrowth was confirmed near the previous site. Compared with 3 recanalized aneurysms, the completely occluded aneurysms showed high mean reductions in velocity and WSS after initial treatment (velocity, 77.6% vs. 57.7%; WSS, 74.2% vs. 52.4%); however, WSS remained high at the region near the previous lesion where the new aneurysm originated. After the second retreatment, there was no recurrence in any patient. Compared with the 3 aneurysms that recanalized, the 4 aneurysms that maintained complete occlusion showed higher reductions in velocity (62.9%) and WSS (71.1%). Our series indicated that hemodynamics might have an important role in recurrence of VADAs. After endovascular treatment, sufficient hemodynamic reduction in aneurysm dome, orifice, and parent vessel may be one of the key factors for preventing recurrence in VADAs. Copyright © 2016 Elsevier Inc. All rights reserved.

An interesting case report of vertebral artery dissection following polytrauma.

PubMed

Acharya, Vikas; Chandrasekaran, Suresh; Nair, Sujit

2016-01-01

The authors present an interesting case of a 19-year-old male who presented as a polytrauma patient following a fall from a height. He was initially managed on the intensive care unit with intracranial pressure bolt monitoring after being intubated and sedated and having his other traumatic injuries stabilized. Upon attempting to wean sedation and extubation a repeat CT scan of the head was undertaken and showed a new area suggested of cerebral infarction, this was a new finding. Further imaging found that he had a cervical vertebral artery dissection following this polytrauma mode of injury. The incidence of vertebral artery dissection following generalized or local trauma is rising but routine imaging/screening in these patients is not undertaken. Our report displays select images related to this case report and emphasizes the consideration of routine imaging in head and neck traumatic injuries to diagnose internal carotid and/or vertebral artery dissections much earlier. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Intracranial hypotension and hypertension in children and adolescents.

PubMed

Ozge, Aynur; Bolay, Hayrunnisa

2014-07-01

The specific aim of this review is to report the features of intracranial pressure changes [spontaneous intracranial hypotension (SIH) and idiopathic intracranial hypertension (IIH)] in children and adolescents, with emphasis on the presentation, diagnosis, and treatment modalities. Headache associated with intracranial pressure changes are relatively rare and less known in children and adolescents. SIH is a specific syndrome involving reduced intracranial pressure with orthostatic headache, frequently encountered connective tissue disorders, and a good prognosis with medical management, initial epidural blood patching, and sometimes further interventions may be required. IIH is an uncommon condition in children and different from the disease in adults, not only with respect to clinical features (likely to present with strabismus and stiff neck rather than headache or pulsatile tinnitus) but also different in outcome. Consequently, specific ICP changes of pediatric ages required specific attention both of exact diagnosis and entire management.

Impact of metal artifact reduction software on image quality of gemstone spectral imaging dual-energy cerebral CT angiography after intracranial aneurysm clipping.

PubMed

Dunet, Vincent; Bernasconi, Martine; Hajdu, Steven David; Meuli, Reto Antoine; Daniel, Roy Thomas; Zerlauth, Jean-Baptiste

2017-09-01

We aimed to assess the impact of metal artifact reduction software (MARs) on image quality of gemstone spectral imaging (GSI) dual-energy (DE) cerebral CT angiography (CTA) after intracranial aneurysm clipping. This retrospective study was approved by the institutional review board, which waived patient written consent. From January 2013 to September 2016, single source DE cerebral CTA were performed in 45 patients (mean age: 60 ± 9 years, male 9) after intracranial aneurysm clipping and reconstructed with and without MARs. Signal-to-noise (SNR), contrast-to-noise (CNR), and relative CNR (rCNR) ratios were calculated from attenuation values measured in the internal carotid artery (ICA) and middle cerebral artery (MCA). Volume of clip and artifacts and relative clip blurring reduction (rCBR) ratios were also measured at each energy level with/without MARs. Variables were compared between GSI and GSI-MARs using the paired Wilcoxon signed-rank test. MARs significantly reduced metal artifacts at all energy levels but 130 and 140 keV, regardless of clips' location and number. The optimal rCBR was obtained at 110 and 80 keV, respectively, on GSI and GSI-MARs images, with up to 96% rCNR increase on GSI-MARs images. The best compromise between metal artifact reduction and rCNR was obtained at 70-75 and 65-70 keV for GSI and GSI-MARs images, respectively, with up to 15% rCBR and rCNR increase on GSI-MARs images. MARs significantly reduces metal artifacts on DE cerebral CTA after intracranial aneurysm clipping regardless of clips' location and number. It may be used to reduce radiation dose while increasing CNR.

Ischemic stroke and intracranial hemorrhage in patients with recurrent glioblastoma multiforme, treated with bevacizumab.

PubMed

Auer, Timo A; Renovanz, Mirjam; Marini, Federico; Brockmann, Marc A; Tanyildizi, Yasemin

2017-07-01

Bevacizumab (BVZ), a monoclonal antibody directed against vascular endothelial growth factor (VEGF), has been suspected to increase the incidence of ischemic stroke (IS) and intracranial hemorrhage (ICH) in GBM patients. Intracranial vascular events, such as IS and ICH, were retrospectively analyzed in 364 MRI scans of 82 patients with recurrent GBM (1st/2nd/3rd relapse). Out of these 82 patients, 40 were treated with BVZ (178 scans) in addition to basic treatment, whereas 42 patients matching for age and gender received basic treatment (186 scans). Distribution of typical vascular risk factors between both groups was analyzed retrospectively. In seven out of 82 patients (8%) vascular events were detected in MRI. Four vascular events were recorded in the BVZ-group (3 IS and 1 ICH), and 3 vascular events were found in the Control-group (1 IS and 2 ICH; p > 0.05 between both groups). Likewise, vascular risk factors (arterial hypertension, diabetes mellitus, obesity, former vascular event, hyperlipidemia, tobacco consumption and/or hypercholesterolemia) did not differ significantly between both groups. BVZ treatment does not seem to be associated with an increased risk for vascular events in patients with GBM in recurrence.

Endovascular Embolization of Visceral Artery Aneurysms with Ethylene-vinyl Alcohol (Onyx): A Case Series

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bratby, M.J.; Lehmann, E.D.; Bottomley, J.

2006-12-15

We report the application of the liquid embolic agent ethylene-vinyl alcohol (Onyx; MicroTherapeutics, Irvine, CA, USA) in the management of visceral artery aneurysms. The technique and indications for using Onyx are discussed with emphasis on the management of wide-necked aneurysms and maintenance of patency of the parent vessel. None of the cases was considered suitable for stent-grafting or embolization with conventional agents. Two aneurysms of the renal artery bifurcation and one aneurysm of the inferior pancreaticoduodenal artery were treated. Following treatment there was complete exclusion of all aneurysms. There was no evidence of end-organ infarction. Follow-up with intervals up tomore » 6 months has shown sustained aneurysm exclusion. Onyx is known to be effective in the management of intracranial aneurysms. Our experience demonstrates the efficacy and applicability of the use of Onyx in the treatment of complex visceral artery aneurysms.« less

Sphenoethmoidal mucoceles with intracranial extension.

PubMed

Close, L G; O'Conner, W E

1983-08-01

Mucoceles of the paranasal sinuses are benign, expansile, locally destructive lesions that are thought to occur secondary to obstruction of the sinus ostia. Nasal and/or ocular signs and symptoms are the usual clinical manifestations of mucoceles arising in the ethmoid and sphenoid sinuses, and intracranial extension is rare. We describe three cases of widely destructive sphenoethmoidal mucoceles extending intracranially, with bone erosion and dural exposure in all cases and brain necrosis in one case.

Intracranial extramedullary haematopoiesis: A case report.

PubMed

Mehta, Samir; Shapey, Jonathan; Pohl, Ute; Vindlacheruvu, Raghu

2015-01-01

Extramedullary haematopoiesis (EMH) is an ectopic production of blood cells to compensate for ineffective haematopoiesis. We report a rare symptomatic presentation of intracranial EMH and discuss its investigation and management. EMH should be considered a differential diagnosis in patients with haemoglobinopathies, haemolytic anaemias and myeloproliferative disorders, who present with symptoms of raised intracranial pressure.

Intracranial hematoma in experienced teenage equestrians.

PubMed

McAbee, G N; Ciminera, P F

1996-10-01

Intracranial hematoma in pediatric equestrians is rare, notwithstanding the lack of uniform standards and requirements for the use of protective headgear during equestrian events. We report two teenage helmeted equestrians who sustained severe head trauma with intracranial hematoma due to falls during equestrian events. Current recommendations for the use of equestrian headgear are reviewed.

Computational Study of Intracranial Aneurysms with Flow Diverting Stent: Correlation with Surgical Outcome

NASA Astrophysics Data System (ADS)

Tang, Yik Sau; Chiu, Tin Lok; Tsang, Anderson Chun On; Leung, Gilberto Ka Kit; Chow, Kwok Wing

2016-11-01

Intracranial aneurysm, abnormal swelling of the cerebral artery, can cause massive internal bleeding in the subarachnoid space upon aneurysm rupture, leading to a high mortality rate. Deployment of a flow diverting stent through endovascular technique can obstruct the blood flow into the aneurysm, thus reducing the risk of rupture. Patient-specific models with both bifurcation and sidewall aneurysms have been investigated. Computational fluid dynamics analysis with physiological boundary conditions has been performed. Several hemodynamic parameters including volume flow rate into the aneurysm and the energy (sum of the fluid kinetic and potential energy) loss between the inlet and outlets were analyzed and compared with the surgical outcome. Based on the simulation results, we conjecture that a clinically successful case might imply less blood flow into the aneurysm after stenting, and thus a smaller amount of energy loss in driving the fluid flow in that portion of artery. This study might provide physicians with quantitative information for surgical decision making. (Partial financial support by the Innovation and Technology Support Program (ITS/011/13 & ITS/150/15) of the Hong Kong Special Administrative Region Government)

Endovascular Embolization of Intracranial Infectious Aneurysms in Patients Undergoing Open Heart Surgery Using n-Butyl Cyanoacrylate.

PubMed

Cheng-Ching, Esteban; John, Seby; Bain, Mark; Toth, Gabor; Masaryk, Thomas; Hui, Ferdinand; Hussain, Muhammad Shazam

2017-03-01

Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce. Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015. Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization. Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.

Arterial injuries after penetrating brain injury in civilians: risk factors on admission head computed tomography.

PubMed

Bodanapally, Uttam K; Saksobhavivat, Nitima; Shanmuganathan, Kathirkamanathan; Aarabi, Bizhan; Roy, Ashis K

2015-01-01

The object of this study was to determine the specific CT findings of the injury profile in penetrating brain injury (PBI) that are risk factors related to intracranial arterial injuries. The authors retrospectively evaluated admission head CTs and accompanying digital subtraction angiography (DSA) studies from patients with penetrating trauma to the head in the period between January 2005 and December 2012. Two authors reviewed the CT images to determine the presence or absence of 30 injury profile variables and quantified selected variables. The CT characteristics in patients with and without arterial injuries were compared using univariate analysis, multivariate analysis, and receiver operating characteristic (ROC) curve analysis to determine the respective risk factors, independent predictors, and optimal threshold values for the continuous variables. Fifty-five patients were eligible for study inclusion. The risk factors for an intracranial arterial injury on univariate analysis were an entry wound over the frontobasal-temporal regions, a bihemispheric wound trajectory, a wound trajectory in proximity to the circle of Willis (COW), a subarachnoid hemorrhage (SAH), a higher SAH score, an intraventricular hemorrhage (IVH), and a higher IVH score. A trajectory in proximity to the COW was the best predictor of injury (OR 6.8 and p = 0.005 for all penetrating brain injuries [PBIs]; OR 13.3 and p = 0.001 for gunshot wounds [GSWs]). Significant quantitative variables were higher SAH and IVH scores. An SAH score of 3 (area under the ROC curve [AUC] for all PBIs 0.72; AUC for GSWs 0.71) and an IVH score of 3 (AUC for all PBIs 0.65; AUC for GSWs 0.65) could be used as threshold values to suggest an arterial injury. The risk factors identified may help radiologists suggest the possibility of arterial injury and prioritize neurointerventional consultation and potential DSA studies.

Utility of Intracranial Pressure Monitoring for Diagnosis of Idiopathic Intracranial Hypertension in the Absence of Papilledema.

PubMed

Bridges, Kelly J; Raslan, Ahmed M

2018-03-01

Idiopathic intracranial hypertension (IIH) is characterized by headaches, visual obscurations, and papilledema, and the diagnosis involves lumbar puncture (LP) with an elevated opening pressure (OP) ≥20 cm H 2 0. When papilledema is absent, the diagnosis becomes less clear. Some physicians have argued that the absence of papilledema rules out IIH, whereas others maintain that elevated OP is sufficient for diagnosis. The authors performed a single-institution 4-year retrospective analysis of patients who underwent invasive intracranial pressure (ICP) monitoring for presumed IIH. A total of 22 patients were reviewed, and 13 had classic symptoms of IIH, documented elevated OP, and absence of papilledema; 5/13 (38%) patients had proven intracranial hypertension as shown by invasive ICP monitoring, whereas 8/13 (62%) had normal ICP. With the use of current diagnostic algorithms of clinical presentation and elevated OP, over half of patients without papilledema in our series would be falsely diagnosed with IIH, which could result in unnecessary medical and surgical intervention. Thus, elevated OP as determined by LP is insufficient to diagnose IIH. On the other hand, the absence of papilledema does not rule out intracranial hypertension. Copyright © 2017 Elsevier Inc. All rights reserved.

Diagnostic TCD for intracranial stenosis in acute stroke patients: experience from a tertiary care stroke center in Karachi, Pakistan.

PubMed

Kamal, Ayeesha Kamran; Rehman, Hasan; Mustafa, Nasir; Ahmed, Bilal; Jan, Mohammad; Wadivalla, Faisal; Kamran, Syed

2015-08-11

Stroke is a common cause of morbidity and mortality around the world. Intracranial large artery atherosclerosis (ICAD) is a frequent etiology of stroke in the South Asian population. There is a need for widely available screening tools to identify patients that are at high risk of stroke due to ICAD for aggressive risk management. This study describes the experience of using the transcranial Doppler (TCD) as a screening tool for this purpose at a tertiary care hospital in a developing country. 86 Patients admitted with stroke due to ICAD underwent TCD for six arteries (Right and left middle cerebral arteries, right and left anterior cerebral arteries, right and left posterior cerebral arteries) in addition to the magnetic resonance angiography (MRA) that is done routinely at the stroke center. Arteries were labeled with either <50 or >50% stenosis by TCD using two separate criteria. These findings were compared with those from the MRA which was used as the gold standard. The proportion of patients that had complete exams (all six arteries insonated by TCD) was reported. The success rate of each TCD criteria in detecting arteries with >50% stenosis was also calculated. There was an attempt to visualize 516 arteries (86 patients with 6 arteries each) of which 375 (72.7%) were successfully insonated. 38 of the 86 (55.8%) patients had complete examinations. MRA reported 43 (8.3%) arteries as stenosed >50%. The TCD did not categorize any artery as stenosed using either criterion and hence failed to classify any stenosed artery correctly. The positive predictive and sensitivity was 0 for this study and the negative predictive value was 93.3%. This study indicates the poor sensitivity of TCD to be a reliable screening tool for the presence of ICAD in the South Asian population in a real life clinical setting.

Cardiac output in idiopathic normal pressure hydrocephalus: association with arterial blood pressure and intracranial pressure wave amplitudes and outcome of shunt surgery

PubMed Central

2011-01-01

Background In patients with idiopathic normal pressure hydrocephalus (iNPH) responding to shunt surgery, we have consistently found elevated intracranial pressure (ICP) wave amplitudes during diagnostic ICP monitoring prior to surgery. It remains unknown why ICP wave amplitudes are increased in these patients. Since iNPH is accompanied by a high incidence of vascular co-morbidity, a possible explanation is that there is reduced vascular compliance accompanied by elevated arterial blood pressure (ABP) wave amplitudes and even altered cardiac output (CO). To investigate this possibility, the present study was undertaken to continuously monitor CO to determine if it is correlated to ABP and ICP wave amplitudes and the outcome of shunting in iNPH patients. It was specifically addressed whether the increased ICP wave amplitudes seen in iNPH shunt responders were accompanied by elevated CO and/or ABP wave amplitude levels. Methods Prospective iNPH patients (29) were clinically graded using an NPH grading scale. Continuous overnight minimally-invasive monitoring of CO and ABP was done simultaneously with ICP monitoring; the CO, ABP, and ICP parameters were parsed into 6-second time windows. Patients were assessed for shunt surgery on clinical grade, Evan's index, and ICP wave amplitude. Follow-up clinical grading was performed 12 months after surgery. Results ICP wave amplitudes but not CO or ABP wave amplitude, showed good correlation with the response to shunt treatment. The patients with high ICP wave amplitude did not have accompanying high levels of CO or ABP wave amplitude. Correlation analysis between CO and ICP wave amplitudes in individual patients showed different profiles [significantly positive in 10 (35%) and significantly negative in 16 (55%) of 29 recordings]. This depended on whether there was also a correlation between ABP and ICP wave amplitudes and on the average level of ICP wave amplitude. Conclusions These results gave no evidence that the increased

The “focus on aneurysm” principle: Classification and surgical principles of management of concurrent arterial aneurysm with arteriovenous malformation causing intracranial hemorrhage

PubMed Central

Jha, Vikas; Behari, Sanjay; Jaiswal, Awadhesh K.; Bhaisora, Kamlesh Singh; Shende, Yogesh P.; Phadke, Rajendra V.

2016-01-01

Context: Concurrent arterial aneurysms (AAs) occurring in 2.7-16.7% patients harboring an arteriovenous malformation (AVM) aggravate the risk of intracranial hemorrhage. Aim: We evaluate the variations of aneurysms simultaneously coexisting with AVMs. A classification-based management strategy and an abbreviated nomenclature that describes their radiological features is also proposed. Setting: Tertiary care academic institute. Statistics: Test of significance applied to determine the factors causing rebleeding in the groups of patients with concurrent AVM and aneurysm and those with only AVMs. Subjects and Methods: Sixteen patients (5 with subarachnoid hemorrhage and 11 with intracerebral/intraventricular hemorrhage; 10 with low flow [LF] and 6 with high flow [HF] AVMs) underwent radiological assessment of Spetzler Martin (SM) grading and flow status of AA + AVM. Their modified Rankin's score (mRS) at admission was compared with their follow-up (F/U) score. Results: Pre-operative mRS was 0 in 5, 2 in 6, 3 in 1, 4 in 3 and 5 in 1; and, SM grade I in 5, II in 3, III in 3, IV in 4 and V in 1 patients, respectively. AA associated AVMs were classified as: (I) Flow-related proximal (n = 2); (II) flow-related distal (n = 3); (III) intranidal (n = 5); (IV) extra-intranidal (n = 2); (V) remote major ipsilateral (n = 1); (VI) remote major contralateral (n = 1); (VII) deep perforator related (n = 1); (VIII) superficial (n = 1); and (IX) distal (n = 0). Their treatment strategy included: Flow related AA, SM I-III LF AVM: aneurysm clipping with AVM excision; nidal-extranidal AA, SM I-III LF AVM: Excision or embolization of both AA + AVM; nidal-extranidal and perforator-related AA, SM IV-V HF AVM: Only endovascular embolization or radiosurgery. Surgical decision-making for remote AA took into account their ipsilateral/contralateral filling status and vessel dominance; and, for AA associated with SM III HF AVM, it varied in each patient based on diffuseness of AVM nidus, flow

Dynamic alteration of regional cerebral blood flow during carotid compression and proof of reversibility.

PubMed

Asahi, Kouichi; Hori, M; Hamasaki, N; Sato, S; Nakanishi, H; Kuwatsuru, R; Sasai, K; Aoki, S

2012-01-01

It is difficult to non-invasively visualize changes in regional cerebral blood flow caused by manual compression of the carotid artery. To visualize dynamic changes in regional cerebral blood flow during and after manual compression of the carotid artery. Two healthy volunteers were recruited. Anatomic features and flow directions in the circle of Willis were evaluated with time-of-flight magnetic resonance angiography (MRA) and two-dimensional phase-contrast (2DPC) MRA, respectively. Regional cerebral blood flow was visualized with territorial arterial spin-labeling magnetic resonance imaging (TASL-MRI). TASL-MRI and 2DPC-MRA were performed in three states: at rest, during manual compression of the right carotid artery, and after decompression. In one volunteer, time-space labeling inversion pulse (Time-SLIP) MRA was performed to confirm collateral flow. During manual carotid compression, in one volunteer, the right thalamus changed to be fed only by the vertebrobasilar system, and the right basal ganglia changed to be fed by the left internal carotid artery. In the other volunteer, the right basal ganglia changed to be fed by the vertebrobasilar system. 2DPC-MRA showed that the flow direction changed in the right A1 segment of the anterior cerebral artery and the right posterior communicating artery. Perfusion patterns and flow directions recovered after decompression. Time-SLIP MRA showed pial vessels and dural collateral circulation when the right carotid artery was manually compressed. Use of TASL-MRI and 2DPC-MRA was successful for non-invasive visualization of the dynamic changes in regional cerebral blood flow during and after manual carotid compression.

Disappearance of Intracranial Extradural Hematomas: Role of Diastatic Cranial Fracture and Intracranial Pressure - An Institutional Experience.

PubMed

Bhat, Abdul Rashid; Kirmani, Altaf Rehman; Wani, Mohammed Afzal

2018-01-01

The intracranial extradural hematoma (EDH) occupies space and creates a mass effect on the brain but the tenacious-adhesions of dura to the inner table of skull counters this effect. The intracranial pressure also pushes the hematoma back while it is held by dural tensile-force. The exploitation of a diastatic fracture, overlying an EDH, by the intracranial pressures to decompress a hematoma out of extradural space into subgaleal/subperiosteal space without surgical intervention. In a period of 15 years, a group of 11 patients among 729 EDHs were managed conservatively. The retrospective study of 11 EDH patients was conducted in the Department of Neurosurgery from January 2000 to December 2014 in 15 years. The statistical law of variance was used as applicable. Analysis of spontaneous disappearance of intracranial EDH among 11 patients revealed that only 1.5% (11/729) EDHs resolved conservatively. The most cases (63.6%) were children and the youngest being 9 months old. All the patients had a diastatic fracture overlying-EDH and were fully conscious. The cause of head injury in most was the fall from height. The hospital stay ranged from 2 to 4 days. All the patients had a good recovery at the time of discharging. The trial of the conservative or spontaneous disappearance of an EDH through a diastatic fracture into the subgaleal space is similar to burr-hole drainage without surgical intervention but depends upon the neurological status, the intracranial pressure of the patient, and the availability of all the modern neurosurgical gadgets.

Computational fluid dynamics modeling of intracranial aneurysms: effects of parent artery segmentation on intra-aneurysmal hemodynamics.

PubMed

Castro, M A; Putman, C M; Cebral, J R

2006-09-01

The purpose of this study is to show the influence of the upstream parent artery geometry on intraaneurysmal hemodynamics of cerebral aneurysms. Patient-specific models of 4 cerebral aneurysms (1 posterior communicating artery [PcomA], 2 middle cerebral artery [MCA], and 1 anterior communicating artery [AcomA]) were constructed from 3D rotational angiography images. Two geometric models were constructed for each aneurysm. One model had the native parent vessel geometry; the second model was truncated approximately 1 cm upstream from the aneurysm, and the parent artery replaced with a straight cylinder. Corresponding finite element grids were generated and computational fluid dynamics simulations were carried out under pulsatile flow conditions. The intra-aneurysmal flow patterns and wall shear stress (WSS) distributions were visualized and compared. Models using the truncated parent vessel underestimated the WSS in the aneurysms in all cases and shifted the impaction zone to the neck compared with the native geometry. These effects were more pronounced in the PcomA and AcomA aneurysms where upstream curvature was substantial. The MCA aneurysm with a long M1 segment was the least effected. The more laminar flow pattern within the parent vessel in truncated models resulted in a less complex intra-aneurysmal flow patterns with fewer vortices and less velocity at the dome. Failure to properly model the inflow stream contributed by the upstream parent artery can significantly influence the results of intra-aneurysmal hemodynamic models. The upstream portion of the parent vessel of cerebral aneurysms should be included to accurately represent the intra-aneurysmal hemodynamics.

Abdominal insufflation for laparoscopy increases intracranial and intrathoracic pressure in human subjects.

PubMed

Kamine, Tovy Haber; Elmadhun, Nassrene Y; Kasper, Ekkehard M; Papavassiliou, Efstathios; Schneider, Benjamin E

2016-09-01

Laparoscopy has emerged as an alternative to laparotomy in select trauma patients. In animal models, increasing abdominal pressure is associated with an increase in intrathoracic and intracranial pressures. We conducted a prospective trial of human subjects who underwent laparoscopic-assisted ventriculoperitoneal shunt placement (lap VPS) with intraoperative measurement of intrathoracic, intracranial and cerebral perfusion pressures. Ten patients undergoing lap VPS were recruited. Abdominal insufflation was performed using CO2 to 0, 8, 10, 12 and 15 mmHg. ICP was measured through the ventricular catheter simultaneously with insufflation and with desufflation using a manometer. Peak inspiratory pressures (PIP) were measured through the endotracheal tube. Blood pressure was measured using a noninvasive blood pressure cuff. End-tidal CO2 (ETCO2) was measured for each set of abdominal pressure level. Pressure measurements from all points of insufflation were compared using a two-way ANOVA with a post hoc Bonferroni test. Mean changes in pressures were compared using t test. ICP and PIP increased significantly with increasing abdominal pressure (both p < 0.01), whereas cerebral perfusion pressure (CPP) and mean arterial pressure did not significantly change with increasing abdominal pressure over the range tested. Higher abdominal pressure values were associated with decreased ETCO2 values. Increased ICP and PIP appear to be a direct result of increasing abdominal pressure, since ETCO2 did not increase. Though CPP did not change over the range tested, the ICP in some patients with 15 mmHg abdominal insufflation reached values as high as 32 cmH2O, which is considered above tolerance, regardless of the CPP. Laparoscopy should be used cautiously, in patients who present with baseline elevated ICP or head trauma as abdominal insufflation affects intracranial pressure.

Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience.

PubMed

Mpotsaris, Anastasios; Kabbasch, Christoph; Borggrefe, Jan; Gontu, Vamsi; Soderman, Michael

2017-04-01

Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results A total of 63 patients with a median age of 67 years (range 33-84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1-29). Median time from stroke onset to recanalization was 408 minutes (range 165-1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15-202 minutes] vs. 130 minutes [range 60-280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of ≥2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0-2) after three months. Conclusions Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high

Follow-up assessment of coiled intracranial aneurysms using zTE MRA as compared with TOF MRA: a preliminary image quality study.

PubMed

Shang, Song'an; Ye, Jing; Luo, Xianfu; Qu, Jianxun; Zhen, Yong; Wu, Jingtao

2017-10-01

To prospectively assess coiled intracranial aneurysms using a novel non-contrast enhanced zero echo time (zTE) MR angiography (MRA) method, and compare its image quality with time-of-flight (TOF) MRA, using digital subtraction angiography (DSA) as reference. Twenty-five patients (10 males and 15 females; age 53.96 ± 12.46 years) were enrolled in this monocentric study. MRA sequences were performed 24 h before DSA. Susceptibility artefact intensity and flow signal within the parent artery were carried out using a 4-point scale. Occlusion status was assessed using the 3-grade Montreal scale. Scores of zTE were higher than TOF for both susceptibility artefact intensity (3.42 ± 0.64, 2.92 ± 0.63, P = 0.01) and flow signal (3.66 ± 0.95, 3.24 ± 1.24, P = 0.01). DSA revealed 17 complete occlusions, five residual neck aneurysms and two residual aneurysms. Inter-observer agreement was excellent (weighted κ: 0.89) for zTE and good (weighted κ: 0.68) for TOF. Intermodality agreement was excellent for zTE (weighted κ: 0.95) and good for TOF (weighted κ: 0.80). Correlations of both MRA sequences with DSA were high (zTE, Spearman's ρ: 0.91; TOF, Spearman's ρ: 0.81). zTE MRA showed promising results for follow-up assessment of coiled intracranial aneurysms and was superior to TOF MRA for visualizing the parent artery and evaluating occlusion status. • Various MRA sequences were applied for follow-up assessment of coiled intracranial aneurysms. • zTE MRA was less sensitive to susceptibility artefacts and haemodynamics. • In this monocentric study, zTE MRA was equivalent to DSA. • zTE MRA maybe an alternative to TOF MRA for follow-up assessment.

Pentobarbital versus thiopental in the treatment of refractory intracranial hypertension in patients with traumatic brain injury: a randomized controlled trial

PubMed Central

Pérez-Bárcena, Jon; Llompart-Pou, Juan A; Homar, Javier; Abadal, Josep M; Raurich, Joan M; Frontera, Guillem; Brell, Marta; Ibáñez, Javier; Ibáñez, Jordi

2008-01-01

Introduction Experimental research has demonstrated that the level of neuroprotection conferred by the various barbiturates is not equal. Until now no controlled studies have been conducted to compare their effectiveness, even though the Brain Trauma Foundation Guidelines recommend that such studies be undertaken. The objectives of the present study were to assess the effectiveness of pentobarbital and thiopental in terms of controlling refractory intracranial hypertension in patients with severe traumatic brain injury, and to evaluate the adverse effects of treatment. Methods This was a prospective, randomized, cohort study comparing two treatments: pentobarbital and thiopental. Patients who had suffered a severe traumatic brain injury (Glasgow Coma Scale score after resuscitation ≤ 8 points or neurological deterioration during the first week after trauma) and with refractory intracranial hypertension (intracranial pressure > 20 mmHg) first-tier measures, in accordance with the Brain Trauma Foundation Guidelines. Results A total of 44 patients (22 in each group) were included over a 5-year period. There were no statistically significant differences in ' baseline characteristics, except for admission computed cranial tomography characteristics, using the Traumatic Coma Data Bank classification. Uncontrollable intracranial pressure occurred in 11 patients (50%) in the thiopental treatment group and in 18 patients (82%) in the pentobarbital group (P = 0.03). Under logistic regression analysis – undertaken in an effort to adjust for the cranial tomography characteristics, which were unfavourable for pentobarbital – thiopental was more effective than pentobarbital in terms of controlling intracranial pressure (odds ratio = 5.1, 95% confidence interval 1.2 to 21.9; P = 0.027). There were no significant differences between the two groups with respect to the incidence of arterial hypotension or infection. Conclusions Thiopental appeared to be more effective than

[Benign intracranial hypertension and chronic hypervitaminosis A].

PubMed

Drouet, A; Valance, J

1998-04-01

We report a case of benign intracranial hypertension due to chronic A-hypervitaminosis and a review of literature with 30 cases in adults and adolescents. The most prominent clinical features are: predominance of young women with normal weight and cured for acne; benign intracranial hypertension without other symptoms in half of cases; wide difference of daily doses and time of continuous intake. Prognosis for vitamin A intoxication is good, when intake of vitamin is discontinued. We reviewed five cases of benign intracranial hypertension due to retinoic acid. The mechanism of vitamin A neurotoxicity is still unknown.

[Intracranial plasmocytomas: biology, diagnosis, and treatment].

PubMed

Belov, A I; Gol'bin, D A

2006-01-01

Intracranial plasmocytomas are a rare abnormality in a neurosurgeon's practice. The plasmocytomas may originate from the skull bones or soft tissue intracranial structures; they may be solitary or occur as a manifestation of multiple myeloma, this type being typical of most intracranial plasmocytomas. Progression of solitary plasmocytoma to multiple myeloma is observed in a number of cases. Preoperative diagnosis involves computed tomography or magnetic resonance imaging; angiography is desirable. The final diagnosis of plasmocytoma is chiefly based on a morphological study. Special immunohistochemical studies yield very promising results; these are likely to be of high prognostic value. Intracranial plasmocytomas require a differential approach and a meticulous examination since the presence or absence of multiple myeloma radically affects prognosis. There are well-defined predictors; however, it is appropriate that craniobasal plasmocytomas show a worse prognosis than plasmocytomas of the skull vault and more commonly progress to multiple myeloma. Plasmocytomas respond to radiotherapy very well. The gold standard of treatment for plasmocytoma is its total removal and adjuvant radiation therapy; however, there is evidence for good results when it is partially removed and undergoes radiotherapy or after radical surgery without subsequent radiation. The role of chemotherapy has not been defined today.

Increased intracranial pressure

MedlinePlus

... the membranes covering the brain and spinal cord) Subdural hematoma (bleeding between the covering of the brain and ... intracranial pressure Patient Instructions Ventriculoperitoneal shunt - discharge Images Subdural hematoma Central nervous system and peripheral nervous system References ...

Bilateral Acute Subdural Hematoma from Ruptured Posterior Communicating Artery Aneurysm

PubMed Central

Boujemâa, H.; Góngora-Rivera, F.; Barragán-Campos, H.; Karachi, K.; Chiras, J.; Sourour, N.

2006-01-01

Summary Brain tumors, hematological diseases and vascular malformations like fistulas or arteriovenous malformations are the most well known causes of non-traumatic subdural hematoma (SDH) 1. Although spontaneous subdural hematoma from ruptured intracranial aneurysm has been reported 2, SDH with non radiographic evidence of subarachnoid hemorrhage is very rare 3,4. Moreover, a patient with acute and bilateral spontaneous subdural hematoma secondary to ruptured left posterior communicating artery aneurysm has not been reported to date. The clinical findings and etiologic mechanisms are discussed. PMID:20569549

Disappearance of Intracranial Extradural Hematomas: Role of Diastatic Cranial Fracture and Intracranial Pressure - An Institutional Experience

PubMed Central

Bhat, Abdul Rashid; Kirmani, Altaf Rehman; Wani, Mohammed Afzal

2018-01-01

Context: The intracranial extradural hematoma (EDH) occupies space and creates a mass effect on the brain but the tenacious-adhesions of dura to the inner table of skull counters this effect. The intracranial pressure also pushes the hematoma back while it is held by dural tensile-force. Aims: The exploitation of a diastatic fracture, overlying an EDH, by the intracranial pressures to decompress a hematoma out of extradural space into subgaleal/subperiosteal space without surgical intervention. Settings and Design: In a period of 15 years, a group of 11 patients among 729 EDHs were managed conservatively. Materials and Methods: The retrospective study of 11 EDH patients was conducted in the Department of Neurosurgery from January 2000 to December 2014 in 15 years. Statistical Analysis Used: The statistical law of variance was used as applicable. Results: Analysis of spontaneous disappearance of intracranial EDH among 11 patients revealed that only 1.5% (11/729) EDHs resolved conservatively. The most cases (63.6%) were children and the youngest being 9 months old. All the patients had a diastatic fracture overlying-EDH and were fully conscious. The cause of head injury in most was the fall from height. The hospital stay ranged from 2 to 4 days. All the patients had a good recovery at the time of discharging. Conclusion: The trial of the conservative or spontaneous disappearance of an EDH through a diastatic fracture into the subgaleal space is similar to burr-hole drainage without surgical intervention but depends upon the neurological status, the intracranial pressure of the patient, and the availability of all the modern neurosurgical gadgets. PMID:29682037

Intracranial, intradural aneurysmal bone cyst.

PubMed

Afnan, Jalil; Snuderl, Matija; Small, Juan

2015-01-01

Aneurysmal bone cysts (ABCs) are benign, expansile, blood-filled, osteolytic lesions with internal septations that may be intraosseous or extraosseous. The cysts may cause local mass effect, and changes in the regional vascular supply necessitating intervention. A case of an intracranial, intradural ABC in a young male patient with progressively severe headaches is presented. This is only the third recorded intradural case, the majority of these rare lesions being extracranial and only a minute fraction intracranial. Copyright © 2015 Elsevier Inc. All rights reserved.

Can proximity of the occipital artery to the greater occipital nerve act as a cause of idiopathic greater occipital neuralgia? An anatomical and histological evaluation of the artery-nerve relationship.

PubMed

Shimizu, Satoru; Oka, Hidehiro; Osawa, Shigeyuki; Fukushima, Yutaka; Utsuki, Satoshi; Tanaka, Ryusui; Fujii, Kiyotaka

2007-06-01

The purpose of this study was to clarify whether proximity of the occipital artery to the greater occipital nerve can act as a cause of occipital neuralgia, analogous to the contribution of intracranial vessels due to compression in cranial nerve neuralgias, represented by trigeminal neuralgias due to compression of the trigeminal nerve root by adjacent arterial loops. Twenty-four suboccipital areas in cadaver heads were studied for anatomical relationships between the occipital artery and the greater occipital nerve, with histopathological assessment of the greater occipital nerve for signs of mechanical damage. The occipital artery and greater occipital nerve were found to cross each other in the nuchal subcutaneous layer, and the latter was constantly situated superficial to the former at the cross point. An indentation of the greater occipital nerve due to the occipital artery was observed at the cross point in all specimens. However, histopathological examination did not reveal any findings of damage to nerves, even in specimens with atherosclerosis of the occipital artery. Although the present study did not provide direct evidence that the occipital artery contributes to occipital neuralgia at the point of contact with the greater occipital nerve, the possibility still cannot be precluded, because the occipital artery may be palpable in areas corresponding to tenderness of the greater occipital nerve. Further studies, including clinical cases, are needed to clarify this issue.

Idiopathic Intracranial Hypertension in Monozygotic Female Twins: Intracranial Pressure Dynamics and Treatment Outcome.

PubMed

Polemikos, Manolis; Heissler, Hans E; Hermann, Elvis J; Krauss, Joachim K

2017-05-01

Familial cases of idiopathic intracranial hypertension (IIH) are exceedingly rare, and its occurrence in monozygotic twins has not been reported previously. We report monozygotic female twins who developed IIH, one at age 25 years and the other at age 28 years. Continuous intracranial pressure (ICP) monitoring confirmed elevated ICP as measured initially by lumbar puncture. In both cases, successful treatment with resolution of papilledema and symptoms relief was achieved after ventriculoperitoneal shunting. This report documents the first case of IIH in monozygotic twins and the associated changes in ICP dynamics. Interestingly, almost equivalent alterations in ICP dynamics were found in the 2 patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Levels of MMP-9 in patients with intracranial aneurysm: Relation with risk factors, size and clinical presentation.

PubMed

Rojas, Hugo Alberto; Fernandes, Karla Simone da Silva; Ottone, Mariana Rodrigues; Magalhães, Kênia Cristina S Fonseca de; Albuquerque, Lucas Alverne Freitas de; Pereira, Julio Leonardo Barbosa; Vieira-Júnior, Gerival; Sousa-Filho, José Lopes; Costa, Bruno Silva; Sandrim, Valéria Cristina; Dellaretti, Marcos; Simões, Renata Toscano

2018-05-01

Intracranial aneurysms are arterial anomalies affecting 2% to 3% of the general population in the world and these ruptures are associated with a high mortality. Some risk factors, such as age, gender, smoking, alcohol, hypertension and familial history are associated with the number of aneurysms and their size. In addition, inflammatory processes within the blood vessels of the brain can activate matrix metalloproteinase-9 (MMP-9), which degrades various components of the extracellular matrix, such as elastin. Thereby, this work has aimed at evaluating the relationship between plasma MMP-9 levels and the risk factors that are associated with intracranial aneurysm, as well as investigating the aneurysm statuses (ruptured and unruptured) and comparing them with the control volunteers. Between August 2014 to June 2016, blood samples were collected from 282 patients (204 ruptured and 78 unruptured saccular intracranial aneurysms) and 286 control volunteers. The MMP-9 plasma levels were measured by ELISA. Statistical analyzes were performed with SPSS software when using parametric or nonparametric tests, after the normality tests. Higher levels of MMP-9 were found in the aneurysm groups as a whole and when they were stratified by rupture status, then compared with the control group (p < 0.0001). When stratifying them by diameter, those smaller than 7 mm presented high levels of MMP-9 (p < 0.0001), especially in the ruptured ones. As for risk factors, hypertension and smoking were the most important. However, hypertension was mostly associated with the ruptured aneurysms (p < 0.0001). High levels of MMP-9 were found in smaller ruptured and unruptured intracranial aneurysms (<7 mm) with strongest statistical associations than other sizes, especially when associated with smoking and hypertension. Copyright © 2018 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Ultrasound non-invasive measurement of intracranial pressure in neurointensive care: A prospective observational study

PubMed Central

Cardim, Danilo; Tajsic, Tamara; Bulman, Michael; Lavinio, Andrea; Gupta, Arun; Hutchinson, Peter J. A.; Czosnyka, Marek

2017-01-01

Background The invasive nature of the current methods for monitoring of intracranial pressure (ICP) has prevented their use in many clinical situations. Several attempts have been made to develop methods to monitor ICP non-invasively. The aim of this study is to assess the relationship between ultrasound-based non-invasive ICP (nICP) and invasive ICP measurement in neurocritical care patients. Methods and findings This was a prospective, single-cohort observational study of patients admitted to a tertiary neurocritical care unit. Patients with brain injury requiring invasive ICP monitoring were considered for inclusion. nICP was assessed using optic nerve sheath diameter (ONSD), venous transcranial Doppler (vTCD) of straight sinus systolic flow velocity (FVsv), and methods derived from arterial transcranial Doppler (aTCD) on the middle cerebral artery (MCA): MCA pulsatility index (PIa) and an estimator based on diastolic flow velocity (FVd). A total of 445 ultrasound examinations from 64 patients performed from 1 January to 1 November 2016 were included. The median age of the patients was 53 years (range 37–64). Median Glasgow Coma Scale at admission was 7 (range 3–14), and median Glasgow Outcome Scale was 3 (range 1–5). The mortality rate was 20%. ONSD and FVsv demonstrated the strongest correlation with ICP (R = 0.76 for ONSD versus ICP; R = 0.72 for FVsv versus ICP), whereas PIa and the estimator based on FVd did not correlate with ICP significantly. Combining the 2 strongest nICP predictors (ONSD and FVsv) resulted in an even stronger correlation with ICP (R = 0.80). The ability to detect intracranial hypertension (ICP ≥ 20 mm Hg) was highest for ONSD (area under the curve [AUC] 0.91, 95% CI 0.88–0.95). The combination of ONSD and FVsv methods showed a statistically significant improvement of AUC values compared with the ONSD method alone (0.93, 95% CI 0.90–0.97, p = 0.01). Major limitations are the heterogeneity and small number of patients

Hypertonic/Hyperoncotic Resuscitation from Shock: Reduced Volume Requirement and Lower Intracranial Pressure

DTIC Science & Technology

1989-10-01

in Dogs with Hemorrhagic Shock and an Intracranial Mass. Seventh International Symposium on Intracranial Pressure and Brain Injury , Ann Arbor, Michigan...with Hemorrhagic Shock and an Intracranial Mass. Seventh International Symposium on Intracranial Pressure and Brain Injury . Intracranial Pressure VII...and MCI US groups. Discussion: Following this severe insult a iETTiFMT3-a clinical head injury combined wit6i hemorrha Ic shock, a cobntnc/h rcctc

Greater effect of stroke thrombolysis in the presence of arterial obstruction.

PubMed

De Silva, Deidre A; Churilov, Leonid; Olivot, Jean-Marc; Christensen, Soren; Lansberg, Maarten G; Mlynash, Michael; Campbell, Bruce C V; Desmond, Patricia; Straka, Matus; Bammer, Roland; Albers, Gregory W; Davis, Stephen M; Donnan, Geoffrey A

2011-10-01

Recanalization of arterial obstruction is associated with improved clinical outcomes. There are no controlled data demonstrating whether arterial obstruction status predicts the treatment effect of intravenous (IV) tissue plasminogen activator (tPA). We aimed to determine if the presence of arterial obstruction improves the treatment effect of IV tPA over placebo in attenuating infarct growth. We analyzed 175 ischemic stroke patients treated in the 3-6 hour time window from the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET) trial (randomized to IV tPA or placebo) and Diffusion and perfusion imaging Evaluation For Understanding Stroke Evolution (DEFUSE) study (all treated with IV tPA). Infarct growth was calculated as the difference between baseline diffusion-weighted imaging (DWI) and final T2 lesion volumes. Baseline arterial obstruction of large intracranial arteries was graded on magnetic resonance angiography (MRA). Among the 116 patients with adequate baseline MRA and final lesion assessment, 72 had arterial obstruction (48 tPA, 24 placebo) and 44 no arterial obstruction (33 tPA, 11 placebo). Infarct growth was lower in the tPA than placebo group (median difference 26ml, 95% confidence interval [CI], 1-50) in patients with arterial obstruction, but was similar in patients with no arterial obstruction (median difference 5ml, 95%CI, -3 to 9). Infarct growth attenuation with tPA over placebo treatment was greater among patients with arterial obstruction than those without arterial obstruction by a median of 32ml (95%CI, 21-43, p < 0.001). The treatment effect of IV tPA over placebo was greater with baseline arterial obstruction, supporting arterial obstruction status as a consideration in selecting patients more likely to benefit from IV thrombolysis. Copyright © 2011 American Neurological Association.

Surgical Treatment of Large or Giant Fusiform Middle Cerebral Artery Aneurysms: A Case Series.

PubMed

Xu, Feng; Xu, Bin; Huang, Lei; Xiong, Ji; Gu, Yuxiang; Lawton, Michael T

2018-04-14

Management of large or giant fusiform middle cerebral artery (MCA) aneurysms represents a significant challenge. To describe the authors' experience in the treatment of large or giant fusiform MCA aneurysm by using various surgical techniques. We retrospectively reviewed a database of aneurysms treated at our division between 2015 and 2017. Overall, 20 patients (11 males, 9 females) were identified, with a mean age of 40.7 years (range, 13-65 years; median, 43 years). Six patients (30%) had ruptured aneurysms and 14 (70%) had unruptured aneurysms. The mean aneurysm size was 19 mm (range, 10-35 mm). The aneurysms involved the prebifurcation in 5 cases, bifurcation in 4 cases, and postbifurcation in 11 cases. The aneurysms were treated by clip reconstruction (n = 5), clip wrapping (n = 1), proximal occlusion or trapping (n = 4), and bypass revascularization (n = 10). Bypasses included 7 low-flow superficial temporal artery-MCA bypasses, 2 high-flow extracranial-intracranial bypasses, and 1 intracranial-intracranial bypass (reanastomosis). Bypass patency was 90%. Nineteen aneurysms (95%) were completely obliterated, and no rehemorrhage occurred during follow-up. There was no procedural-related mortality. Clinical outcomes were good (modified Rankin Scale score ≤2) in 18 of 20 patients (90%) at the last follow-up. Surgical treatment strategy for large or giant fusiform MCA aneurysms should be determined on an individual basis, based on aneurysm morphology, location, size, and clinical status. Favorable outcomes can be achieved by various surgical techniques, including clip reconstruction, wrap clipping, aneurysm trapping, aneurysm excision followed by reanastomosis, and partial trapping with bypass revascularization. Copyright © 2018 Elsevier Inc. All rights reserved.

A whole-body mathematical model for intracranial pressure dynamics.

PubMed

Lakin, William D; Stevens, Scott A; Tranmer, Bruce I; Penar, Paul L

2003-04-01

Most attempts to study intracranial pressure using lumped-parameter models have adopted the classical "Kellie-Monro Doctrine," which considers the intracranial space to be a closed system that is confined within the nearly-rigid skull, conserves mass, and has equal inflow and outflow. The present work revokes this Doctrine and develops a mathematical model for the dynamics of intracranial pressures, volumes, and flows that embeds the intracranial system in extensive whole-body physiology. The new model consistently introduces compartments representing the tissues and vasculature of the extradural portions of the body, including both the thoracic region and the lower extremities. In addition to vascular connections, a spinal-subarachnoid cerebrospinal fluid (CSF) compartment bridges intracranial and extracranial physiology allowing explict buffering of intracranial pressure fluctuations by the spinal theca. The model contains cerebrovascular autoregulation, regulation of systemic vascular pressures by the sympathetic nervous system, regulation of CSF production in the choroid plexus, a lymphatic system, colloid osmotic pressure effects, and realistic descriptions of cardiac output. To validate the model in situations involving normal physiology, the model's response to a realistic pulsatile cardiac output is examined. A well-known experimentally-derived intracranial pressure-volume relationship is recovered by using the model to simulate CSF infusion tests, and the effect on cerebral blood flow of a change in body position is also examined. Cardiac arrest and hemorrhagic shock are simulated to demonstrate the predictive capabilities of the model in pathological conditions.

Brain Stem Infarction Due to Basilar Artery Dissection in a Patient with Moyamoya Disease Four Years after Successful Bilateral Revascularization Surgeries.

PubMed

Abe, Takatsugu; Fujimura, Miki; Mugikura, Shunji; Endo, Hidenori; Tominaga, Teiji

2016-06-01

Moyamoya disease (MMD) is a rare cerebrovascular disease with an unknown etiology and is characterized by intrinsic fragility in the intracranial vascular walls such as the affected internal elastic lamina and thinning medial layer. The association of MMD with intracranial arterial dissection is extremely rare, whereas that with basilar artery dissection (BAD) has not been reported previously. A 46-year-old woman developed brain stem infarction due to BAD 4 years after successful bilateral superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis for ischemic-onset MMD. She presented with sudden occipitalgia and subsequently developed transient dysarthria and mild hemiparesis. Although a transient ischemic attack was initially suspected, her condition deteriorated in a manner that was consistent with left hemiplegia with severe dysarthria. Magnetic resonance (MR) imaging revealed brain stem infarction, and MR angiography delineated a double-lumen sign in the basilar artery, indicating BAD. She was treated conservatively and brain stem infarction did not expand. One year after the onset of brain stem infarction, her activity of daily living is still dependent (modified Rankin Scale of 4), and there were no morphological changes associated with BAD or recurrent cerebrovascular events during the follow-up period. The association of MMD with BAD is extremely rare. While considering the common underlying pathology such as an affected internal elastic lamina and fragile medial layer, the occurrence of BAD in a patient with MMD in a stable hemodynamic state is apparently unique. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Intracranial aneurysms: optimized diagnostic tools call for thorough interdisciplinary treatment strategies.

PubMed

Mueller, Oliver M; Schlamann, Marc; Mueller, Daniela; Sandalcioglu, I Erol; Forsting, Michael; Sure, Ulrich

2011-09-01

Intracranial aneurysms (IAs) require deliberately selected treatment strategies as they are incrementally found prior to rupture and deleterious subarachnoid haemorrhage (SAH). Multiple and recurrent aneurysms necessitate both neurointerventionalists and neurosurgeons to optimize aneurysmal occlusion in an interdisciplinary effort. The present study was conducted to condense essential strategies from a single neurovascular centre with regard to the lessons learned. Medical charts of 321 consecutive patients treated for IAs at our centre from September 2008 until December 2010 were retrospectively analysed for clinical presentation of the aneurysms, multiplicity and treatment pathways. In addition, a selective Medline search was performed. A total of 321 patients with 492 aneurysms underwent occlusion of their symptomatic aneurysm: 132 (41.1%) individuals were treated surgically, 189 (58.2%) interventionally; 138 patients presented with a SAH, of these 44.2% were clipped and 55.8% were coiled. Aneurysms of the middle cerebral artery were primarily occluded surgically (88), whereas most of the aneurysms of the internal carotid artery and anterior communicating artery (114) were treated endovascularly. Multiple aneurysms (range 2-5 aneurysms/individual) were diagnosed in 98 patients (30.2%). During the study period 12 patients with recurrent aneurysms were allocated to another treatment modality (previously clip to coil and vice versa). Our data show that successful interdisciplinary occlusion of IAs is based on both neurosurgical and neurointerventional therapy. In particular, multiple and recurrent aneurysms require tailored individual approaches to aneurysmal occlusion. This is achieved by a consequent interdisciplinary pondering of the optimal strategy to occlude IAs in order to prevent SAH.

Onyx HD-500 embolization of intracranial aneurysms: modified technique using continuous balloon inflation under conscious sedation.

PubMed

Rahme, Ralph; Grande, Andrew; Jimenez, Lincoln; Abruzzo, Todd A; Ringer, Andrew J

2014-08-01

The conventional technique of intracranial aneurysm embolization using Onyx HD-500 (ev3 Neurovascular, Irvine, CA, USA) involves repetitive balloon inflation-deflation cycles under general anesthesia. By limiting parent artery occlusion to 5 minutes, this cyclic technique is thought to minimize cerebral ischemia. However, intermittent balloon deflation may lengthen procedure time and allow balloon migration, resulting in intimal injury or Onyx leakage. We report our experience using a modified technique of uninterrupted Onyx injection with continuous balloon occlusion under conscious sedation. All Onyx embolization procedures for unruptured aneurysms performed by the senior author (A.J.R.) between September 2008 and April 2010 were retrospectively reviewed. Demographic, clinical, angiographic, and procedural data were recorded. Twenty-four embolization procedures were performed in 21 patients with 23 aneurysms, including four recurrences. Twenty aneurysms (87%) involved the paraclinoid or proximal supraclinoid internal carotid artery. Size ranged from 2.5 to 24mm and neck diameter from 2 to 8mm. The modified technique was employed in 19 cases. All but one patient (94.4%) tolerated continuous balloon inflation. Complete occlusion was achieved in 20 aneurysms (83.3%) and subtotal occlusion in three (12.5%). Stable angiographic results were seen in 85%, 94%, 94%, and 100% of patients at 6, 12, 24, and 36months, respectively. There were no deaths. Permanent non-disabling neurological morbidity occurred in one patient (4.2%). Minor, transient, and/or angiographic complications were seen in three patients (12.5%), none related to the technique itself. Onyx embolization of unruptured intracranial aneurysms can be safely and effectively performed using continuous balloon inflation under conscious sedation. Copyright © 2014 Elsevier Ltd. All rights reserved.

Spontaneous acute subdural hematoma: A rare presentation of a dural intracranial fistula.

PubMed

de Aguiar, Guilherme Brasileiro; Veiga, José Carlos Esteves; Silva, João Miguel de Almeida; Conti, Mario Luiz Marques

2016-03-01

Dural arteriovenous fistulas are acquired lesions between the meningeal arteries and their associated draining veins. They may have highly variable clinical presentations and evolution, from severe neurological deficit to no or trivial symptoms. Intracranial hemorrhage occurs in less than 24% of all dural fistulas, and the bleeding is usually subarachnoid, more infrequently intracerebral, and rarely in the subdural space. Here, we present a rare case of a patient who presented with a subdural spontaneous hemorrhage. After investigation by cerebral angiography, the diagnosis of a dural arteriovenous fistula was made. The patient underwent uneventful endovascular treatment. As there are with only a few reports in the literature of such a presentation, we present this patient and perform a brief review of the literature. Copyright © 2015 Elsevier Ltd. All rights reserved.

Blood Pressure Is the Determinant for the Increased Risk for Intracranial Arterial Stenosis in Subjects with Elevated Glycated Hemoglobin Levels: The Kangbuk Samsung Health Study.

PubMed

Oh, Hyung-Geun; Rhee, Eun-Jung

2016-11-01

Ischemic stroke is known to be an important vascular complication of diabetes. Intracranial arterial stenosis (ICAS) is considered as an important cause of stroke in Asians. We aimed to analyze the risk for ICAS assessed by transcranial Doppler (TCD) ultrasonography in different groups of young Korean subjects divided by glycated hemoglobin (HbA1c) levels. This study included 10,437 participants without history of cardiovascular diseases (81.3% men, mean age 43 years) from a health screening program, in whom TCD ultrasonography was used to detect greater than 50% ICAS based on criteria modified from the SONIA (Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis) trial. The subjects were divided into 3 groups according to HbA1c levels: HbA1c < 5.7%, 5.7 ≤ HbA1c < 6.5%, and HbA1c ≥ 6.5% or under medication for diabetes. Among the participants, 3.0% of the subjects had ICAS. The subjects with ICAS tended to have higher mean HbA1c level compared with those without ICAS (5.8 ± .8 versus 5.7 ± .6, P = .063). The proportion of subjects with ICAS significantly increased as the HbA1c increased from the first to the third group (2.8%, 3.0%, 4.6%, P for linear trend = .022). In logistic regression analysis with ICAS as the dependent variable, the group with HbA1c ≥ 6.5% showed significantly increased odds ratio for ICAS with subjects with HbA1c < 5.7% as the reference after adjustment for confounding variables (1.575, 95% confidence interval 1.056-2.347). However, this significance disappeared with inclusion of presence of hypertension in the model. The risk for ICAS assessed by TCD was increased in young Korean subjects with HbA1c ≥ 6.5%. However, this significance was attenuated after adjustment for presence of hypertension, suggesting the importance of hypertension in ICAS. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Extrinsic cerebral venous sinus obstruction resulting in intracranial hypertension

PubMed Central

Goldsmith, P; Burn, D; Coulthard, A; Jenkins, A

1999-01-01

We report the case of a 70-year-old man reporting with headache and visual disturbances who was being treated for prostate cancer. Investigations showed him to have intracranial hypertension caused by venous sinus obstruction. Patients with metastatic disease and raised intracranial pressure in the absence of focal signs should be considered as possible cases of venous outflow obstruction.


Keywords: intracranial hypertension; venous sinus thrombosis; malignancy PMID:10616691

Management of raised intracranial pressure and hyperosmolar therapy.

PubMed

Ropper, Allan H

2014-06-01

The management of raised intracranial pressure is undergoing rapid change. The choice of medical treatments to reduce intracranial pressure varies between institutions and regions of the world. The mainstay of therapy, however, continues to be the infusion of a hyperosmolar solution to achieve an osmotic gradient to force the exit of water from the brain. This review introduces the basic concepts of raised intracranial pressure, summarises several recent studies that have challenged dogma in the field, and provides practical advice on hyperosmolar treatment, based on personal experience and a critical reading of the literature.

[Measurement of intracranial hematoma volume by personal computer].

PubMed

DU, Wanping; Tan, Lihua; Zhai, Ning; Zhou, Shunke; Wang, Rui; Xue, Gongshi; Xiao, An

2011-01-01

To explore the method for intracranial hematoma volume measurement by the personal computer. Forty cases of various intracranial hematomas were measured by the computer tomography with quantitative software and personal computer with Photoshop CS3 software, respectively. the data from the 2 methods were analyzed and compared. There was no difference between the data from the computer tomography and the personal computer (P>0.05). The personal computer with Photoshop CS3 software can measure the volume of various intracranial hematomas precisely, rapidly and simply. It should be recommended in the clinical medicolegal identification.

Three-dimensional stereotactic atlas of the extracranial vasculature correlated with the intracranial vasculature, cranial nerves, skull and muscles

PubMed Central

Shoon Let Thaung, Thant; Choon Chua, Beng; Hnin Wut Yi, Su; Yang, Yili; Urbanik, Andrzej

2015-01-01

Our objective was to construct a 3D, interactive, and reference atlas of the extracranial vasculature spatially correlated with the intracranial blood vessels, cranial nerves, skull, glands, and head muscles. The atlas has been constructed from multiple 3T and 7T magnetic resonance angiogram (MRA) brain scans, and 3T phase contrast and inflow MRA neck scans of the same specimen in the following steps: vessel extraction from the scans, building 3D tubular models of the vessels, spatial registration of the extra- and intracranial vessels, vessel editing, vessel naming and color-coding, vessel simplification, and atlas validation. This new atlas contains 48 names of the extracranial vessels (25 arterial and 23 venous) and it has been integrated with the existing brain atlas. The atlas is valuable for medical students and residents to easily get familiarized with the extracranial vasculature with a few clicks; is useful for educators to prepare teaching materials; and potentially can serve as a reference in the diagnosis of vascular disease and treatment, including craniomaxillofacial surgeries and radiologic interventions of the face and neck. PMID:25923683

Black blood MRI in suspected large artery primary angiitis of the central nervous system.

PubMed

Pfefferkorn, Thomas; Linn, Jennifer; Habs, Maximilian; Opherk, Christina; Cyran, Clemens; Ottomeyer, Caroline; Straube, Andreas; Dichgans, Martin; Nikolaou, Konstantin; Saam, Tobias

2013-07-01

Single case reports suggest that black blood MRI (T1-weighted fat and blood suppressed sequences with and without contrast injection; BB-MRI) may visualize intracranial vessel wall contrast enhancement (CE) in primary angiitis of the central nervous system (PACNS). In this single-center observational pilot study we prospectively investigated the value of BB-MRI in the diagnosis of large artery PACNS. Patients with suspected large artery PACNS received a standardized diagnostic program including BB-MRI. Vessel wall CE was graded (grade 0-2) by two experienced readers blinded to clinical data and correlated to the final diagnosis. Four of 12 included patients received a final diagnosis of PACNS. All of them showed moderate (grade 1) to strong (grade 2) vessel wall CE at the sites of stenosis. A moderate (grade 1) vessel wall CE grade was also observed in 6 of the remaining 8 patients in whom alternative diagnoses were made: arteriosclerotic disease (n = 4), intracranial dissection (n = 1), and Moyamoya disease (n = 1). Our pilot study demonstrates that vessel wall CE is a frequent finding in PACNS and its mimics. Larger trials will be necessary to evaluate the utility of BB-MRI in the diagnostic workup of PACNS. Copyright © 2012 by the American Society of Neuroimaging.

Investigation of vasculogenic mimicry in intracranial hemangiopericytoma.

PubMed

Zhang, Zhen; Han, Yun; Zhang, Keke; Teng, Liangzhu

2011-01-01

Vasculogenic mimicry (VM) has increasingly been recognized as a form of angiogenesis. Previous studies have shown that the existence of VM is associated with poor clinical prognosis in certain malignant tumors. However, whether VM is present and clinically significant in intracranial hemangiopericytoma (HPC) is unknown. The present study was therefore designed to examine the expression of VM in intracranial HPC and its correlation with matrix metalloprotease-2 (MMP-2) and vascular endothelial growth factor (VEGF). A total of 17 intracranial HPC samples, along with complete clinical and pathological data, were collected for our study. Immunohistochemistry was performed to stain tissue sections for CD34, periodic acid-Schiff, VEGF and MMP-2. The levels of VEGF and MMP-2 were compared between tumor samples with and without VM. The results showed that VM existed in 12 of 17 (70.6%) intracranial HPC samples. The presence of VM in tumors was associated with tumor recurrence (P<0.05) and expression of MMP-2 (P<0.05). However, there was no difference in the expression of VEGF between groups with and without VM.

Vortex dynamics in ruptured and unruptured intracranial aneurysms

NASA Astrophysics Data System (ADS)

Trylesinski, Gabriel; Varble, Nicole; Xiang, Jianping; Meng, Hui

2013-11-01

Intracranial aneurysms (IAs) are potentially devastating pathological dilations of arterial walls that affect 2-5% of the population. In our previous CFD study of 119 IAs, we found that ruptured aneurysms were correlated with complex flow pattern and statistically predictable by low wall shear stress and high oscillatory shear index. To understand flow mechanisms that drive the pathophysiology of aneurysm wall leading to either stabilization or growth and rupture, we aim at exploring vortex dynamics of aneurysmal flow and provide insight into the correlation between the previous predictive morphological parameters and wall hemodynamic metrics. We adopt the Q-criterion definition of coherent structures (CS) and analyze the CS dynamics in aneurysmal flows for both ruptured and unruptured IA cases. For the first time, we draw relevant biological conclusions concerning aneurysm flow mechanisms and pathophysiological outcome. In pulsatile simulations, the coherent structures are analyzed in these 119 patient-specific geometries obtained using 3D angiograms. The images were reconstructed and CFD were performed. Upon conclusion of this work, better understanding of flow patterns of unstable aneurysms may lead to improved clinical outcome.

The major influence of the atmosphere on intracranial pressure: an observational study

NASA Astrophysics Data System (ADS)

Herbowski, Leszek

2017-01-01

The impact of the atmosphere on human physiology has been studied widely within the last years. In practice, intracranial pressure is a pressure difference between intracranial compartments and the surrounding atmosphere. This means that gauge intracranial pressure uses atmospheric pressure as its zero point, and therefore, this method of pressure measurement excludes the effects of barometric pressure's fluctuation. The comparison of these two physical quantities can only take place through their absolute value relationship. The aim of this study is to investigate the direct effect of barometric pressure on the absolute intracranial pressure homeostasis. A prospective observational cross-sectional open study was conducted in Szczecin, Poland. In 28 neurosurgical patients with suspected normal-pressure hydrocephalus, intracranial intraventricular pressure was monitored in a sitting position. A total of 168 intracranial pressure and atmospheric pressure measurements were performed. Absolute atmospheric pressure was recorded directly. All values of intracranial gauge pressure were converted to absolute pressure (the sum of gauge intracranial pressure and local absolute atmospheric pressure). The average absolute mean intracranial pressure in the patients is 1006.6 hPa (95 % CI 1004.5 to 1008.8 hPa, SEM 1.1), and the mean absolute atmospheric pressure is 1007.9 hPa (95 % CI 1006.3 to 1009.6 hPa, SEM 0.8). The observed association between atmospheric and intracranial pressure is strongly significant (Spearman correlation r = 0.87, p < 0.05) and all the measurements are perfectly reliable (Bland-Altman coefficient is 4.8 %). It appears from this study that changes in absolute intracranial pressure are related to seasonal variation. Absolute intracranial pressure is shown to be impacted positively by atmospheric pressure.

Middle cerebral artery dissection causing subarachnoid hemorrhage and cerebral infarction: Trapping with high-flow bypass preserving the lenticulostriate artery

PubMed Central

Ono, Hideaki; Inoue, Tomohiro; Suematsu, Shinya; Tanishima, Takeo; Tamura, Akira; Saito, Isamu; Saito, Nobuhito

2017-01-01

Background: Spontaneous intracranial arterial dissection (IAD) is an increasingly important cause of stroke, such as subarachnoid hemorrhage (SAH) and hemodynamic or thromboembolic cerebral ischemia. IAD usually occurs in the posterior circulation, and is relatively rare in the anterior circulation including the middle cerebral artery (MCA). Various surgical and endovascular methods to reduce blood flow in the dissected lesion have been proposed, but no optimum treatment has been established. Case Description: An 80-year-old woman with dissection in the M1 portion of the MCA manifesting as SAH presented with repeated hemorrhage and cerebral infarction in the area of the inferior trunk of the MCA. High-flow bypass to the MCA was performed and the dissecting lesion was trapped. Prevention of repeated hemorrhage was achieved, and blood flow was preserved to the lenticulostriate artery as well as the MCA area distal to the lesion. Conclusions: Treatment strategy for IAD of the MCA should be planned for each patient and condition, and surgery should be performed promptly to prevent critical rebleeding given the high recurrence rate. In addition, preventing re-rupture of the IAD, and preserving important perforators around the lesion and blood flow distal to the dissection should be targeted by the treatment strategy. PMID:28808606

Ultrasonic Apparatus and Technique to Measure Changes in Intracranial Pressure

NASA Technical Reports Server (NTRS)

Yost, William T. (Inventor); Cantrell, John H. (Inventor)

2002-01-01

Changes in intracranial pressure can be measured dynamically and non-invasively by monitoring one or more cerebrospinal fluid pulsatile components. Pulsatile components such as systolic and diastolic blood pressures are partially transferred to the cerebrospinal fluid by way of blood vessels contained in the surrounding brain tissue and membrane. As intracranial pressure varies these cerebrospinal fluid pulsatile components also vary. Thus, intracranial pressure can be dynamically measured. Furthermore, use of acoustics allows the measurement to be completely non-invasive. In the preferred embodiment, phase comparison of a reflected acoustic signal to a reference signal using a constant frequency pulsed phase-locked-loop ultrasonic device allows the pulsatile components to be monitored. Calibrating the device by inducing a known change in intracranial pressure allows conversion to changes in intracranial pressure.

Effects of Early Bedside Cycle Exercise on Intracranial Pressure and Systemic Hemodynamics in Critically Ill Patients in a Neurointensive Care Unit.

PubMed

Thelandersson, Anneli; Nellgård, Bengt; Ricksten, Sven-Erik; Cider, Åsa

2016-12-01

Physiotherapy is an important part of treatment after severe brain injuries and stroke, but its effect on intracranial and systemic hemodynamics is minimally investigated. Therefore, the aim of this study was to assess the effects of an early bedside cycle exercise on intracranial and systemic hemodynamics in critically ill patients when admitted to a neurointensive care unit (NICU). Twenty critically ill patients suffering from brain injuries or stroke were included in this study performed in the NICU at Sahlgrenska University Hospital. One early implemented exercise session was performed using a bedside cycle ergometer for 20 min. Intracranial and hemodynamic variables were measured two times before, three times during, and two times after the bedside cycling exercise. Analyzed variables were intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial blood pressure (MAP), heart rate (HR), peripheral oxygen saturation (SpO 2 ), cardiac output (CO), stroke volume (SV), and stroke volume variation (SVV). The cycling intervention was conducted within 7 ± 5 days after admission to the NICU. Cycle exercise increased MAP (p = 0.029) and SV (p = 0.003) significantly. After exercise CO, SV, MAP, and CPP decreased significantly, while no changes in HR, SVV, SpO 2 , or ICP were noted when compared to values obtained during exercise. There were no differences in data obtained before versus after exercise. Early implemented exercise with a bedside cycle ergometer, for patients with severe brain injuries or stroke when admitted to a NICU, is considered to be a clinically safe procedure.

Early Detection of Increased Intracranial Pressure Episodes in Traumatic Brain Injury: External Validation in an Adult and in a Pediatric Cohort.

PubMed

Güiza, Fabian; Depreitere, Bart; Piper, Ian; Citerio, Giuseppe; Jorens, Philippe G; Maas, Andrew; Schuhmann, Martin U; Lo, Tsz-Yan Milly; Donald, Rob; Jones, Patricia; Maier, Gottlieb; Van den Berghe, Greet; Meyfroidt, Geert

2017-03-01

A model for early detection of episodes of increased intracranial pressure in traumatic brain injury patients has been previously developed and validated based on retrospective adult patient data from the multicenter Brain-IT database. The purpose of the present study is to validate this early detection model in different cohorts of recently treated adult and pediatric traumatic brain injury patients. Prognostic modeling. Noninterventional, observational, retrospective study. The adult validation cohort comprised recent traumatic brain injury patients from San Gerardo Hospital in Monza (n = 50), Leuven University Hospital (n = 26), Antwerp University Hospital (n = 19), Tübingen University Hospital (n = 18), and Southern General Hospital in Glasgow (n = 8). The pediatric validation cohort comprised patients from neurosurgical and intensive care centers in Edinburgh and Newcastle (n = 79). None. The model's performance was evaluated with respect to discrimination, calibration, overall performance, and clinical usefulness. In the recent adult validation cohort, the model retained excellent performance as in the original study. In the pediatric validation cohort, the model retained good discrimination and a positive net benefit, albeit with a performance drop in the remaining criteria. The obtained external validation results confirm the robustness of the model to predict future increased intracranial pressure events 30 minutes in advance, in adult and pediatric traumatic brain injury patients. These results are a large step toward an early warning system for increased intracranial pressure that can be generally applied. Furthermore, the sparseness of this model that uses only two routinely monitored signals as inputs (intracranial pressure and mean arterial blood pressure) is an additional asset.

The Middle Temporal Artery: Surgical Anatomy and Exposure for Cerebral Revascularization.

PubMed

Rubio, Roberto Rodriguez; Lawton, Michael T; Kola, Olivia; Tabani, Halima; Yousef, Sonia; Meybodi, Ali Tayebi; Burkhardt, Jan-Karl; El-Sayed, Ivan; Benet, Arnau

2018-02-01

The middle temporal artery (MTA) is the proximal medial branch of the superficial temporal artery (STA), supplying the temporalis muscle along with deep temporal arteries. Its use in vascularized flaps for reconstructive and otologic procedures has been described, yet its potential use in neurosurgery has not been studied. We report a novel technique for exposing the MTA and evaluated its characteristics for extracranial-intracranial cerebrovascular bypass. After a curvilinear frontotemporal incision in 10 cadaveric specimens, the STA was dissected from distal to proximal. The horizontal portion of MTA was found posterolateral to the posterior end of the zygomatic root and was followed proximally until its origin and distally until its 2 terminal branches. The total length, visible branches, and caliber of MTA were measured. The mean total harvested length of MTA was 31.7 ± 5.1 mm, with an average proximal caliber of 1.7 ± 0.4 mm, and distal caliber of 1.3 ± 0.5 mm. There were 4-6 terminal MTA branches. The caliber of the proximal STA trunk was 2.5 ± 0.5 mm. The origin of the MTA was visible with a mean distance of 16.9 ± 4.8 mm inferior to the PEZR. The parotid gland was traversed and a communicating auriculotemporal nerve to the temporal branch of the facial nerve crossed MTA in 2 specimens. MTA can be safely harvested with an anterolateral approach, following its horizontal portion at the level of the zygomatic root, which is constant. The length and caliber of MTA makes it a potential alternative donor vessel or interposition graft for extracranial-intracranial bypass, especially when other donors are unavailable. Copyright © 2017 Elsevier Inc. All rights reserved.

Intracranial aneurysm formation in siblings with pseudoxanthoma elasticum: case report.

PubMed

Defillo, A; Nussbaum, E S

2010-09-01

Although intracranial aneurysms have been associated with many hereditary collagen disorders, the incidence of brain aneurysms in pseudoxanthoma elasticum (PXE) appears to be exceedingly low and uncertain. We describing a rare case of a sisters with PXE who both developed intracranial aneurysms. This report supports the previously questioned hypothetical association between PXE and intracranial aneurysms.

Hypothermia for Intracranial Hypertension after Traumatic Brain Injury.

PubMed

Andrews, Peter J D; Sinclair, H Louise; Rodriguez, Aryelly; Harris, Bridget A; Battison, Claire G; Rhodes, Jonathan K J; Murray, Gordon D

2015-12-17

In patients with traumatic brain injury, hypothermia can reduce intracranial hypertension. The benefit of hypothermia on functional outcome is unclear. We randomly assigned adults with an intracranial pressure of more than 20 mm Hg despite stage 1 treatments (including mechanical ventilation and sedation management) to standard care (control group) or hypothermia (32 to 35°C) plus standard care. In the control group, stage 2 treatments (e.g., osmotherapy) were added as needed to control intracranial pressure. In the hypothermia group, stage 2 treatments were added only if hypothermia failed to control intracranial pressure. In both groups, stage 3 treatments (barbiturates and decompressive craniectomy) were used if all stage 2 treatments failed to control intracranial pressure. The primary outcome was the score on the Extended Glasgow Outcome Scale (GOS-E; range, 1 to 8, with lower scores indicating a worse functional outcome) at 6 months. The treatment effect was estimated with ordinal logistic regression adjusted for prespecified prognostic factors and expressed as a common odds ratio (with an odds ratio <1.0 favoring hypothermia). We enrolled 387 patients at 47 centers in 18 countries from November 2009 through October 2014, at which time recruitment was suspended owing to safety concerns. Stage 3 treatments were required to control intracranial pressure in 54% of the patients in the control group and in 44% of the patients in the hypothermia group. The adjusted common odds ratio for the GOS-E score was 1.53 (95% confidence interval, 1.02 to 2.30; P=0.04), indicating a worse outcome in the hypothermia group than in the control group. A favorable outcome (GOS-E score of 5 to 8, indicating moderate disability or good recovery) occurred in 26% of the patients in the hypothermia group and in 37% of the patients in the control group (P=0.03). In patients with an intracranial pressure of more than 20 mm Hg after traumatic brain injury, therapeutic hypothermia plus

Noninvasive assessment of intracranial elastance and pressure in spontaneous intracranial hypotension by MRI.

PubMed

Tsai, Yi-Hsin; Chen, Hung-Chieh; Tung, Hsin; Wu, Yi-Ying; Chen, Hsian-Min; Pan, Kuan-Jung; Cheng, Da-Chuan; Chen, Jeon-Hor; Chen, Clayton Chi-Chang; Chai, Jyh-Wen; Shen, Wu-Chung

2018-02-13

Spontaneous intracranial hypotension (SIH) is often misdiagnosed, and can lead to severe complications. Conventional MR sequences show a limited ability to aid in this diagnosis. MR-based intracranial pressure (MR-ICP) may be able to detect changes of intracranial elastance and pressure. To determine whether MR-ICP is able to differentiate SIH patients from normal subjects, improve diagnostic sensitivity, and provide an insight into the pathophysiology. Prospective. Twenty-eight SIH cases with orthostatic headache and 20 healthy volunteers. Cine phase-contrast MRI on a 1.5T scanner. Intracranial elastance (IE) was derived from the ratio of the peak-to-peak cerebrospinal fluid (CSF) pressure gradient (PG csf-pp ) and intracranial volume change, obtained by summing all flows before each sequential cardiac frame. Student's t-test was used to compare the MR-ICP indexes and flow parameters between SIH patients and healthy volunteers (P < 0.01). The SIH patients with cervical epidural venous dilatation (EVD) had an IE of 0.121 ± 0.027 mmHg/cm/ml, significantly higher than that of the normal volunteers (0.085 ± 0.027 mmHg/cm/ml; P = 0.002). In contradistinction, the EVD-negative SIH patients, including four with no sign of CSF leaks, had significantly lower IE (0.055 ± 0.012 mmHg/cm/ml) compared with the normal volunteers and the EVD-positive group (P = 0.001, P < 0.001). The EVD-negative patients had significantly lower PG csf-pp (0.024 ± 0.007 mmHg/cm) compared with the normal volunteers and the EVD-positive group (0.035 ± 0.011 mmHg/cm, 0.040 ± 0.010 mmHg/cm; P = 0.003, P < 0.001). Additionally, the MRI flow study showed a significant decrease in transcranial inflow and outflow of SIH patients (P < 0.01). We found that the MR-ICP method is potentially more sensitive than morphological MRI in the early diagnosis of SIH. Also, contrary to common belief, our results suggest that an abnormal craniospinal elastance

Risk factors for neurological worsening and symptomatic watershed infarction in internal carotid artery aneurysm treated by extracranial-intracranial bypass using radial artery graft.

PubMed

Matsukawa, Hidetoshi; Tanikawa, Rokuya; Kamiyama, Hiroyasu; Tsuboi, Toshiyuki; Noda, Kosumo; Ota, Nakao; Miyata, Shiro; Oda, Jumpei; Takeda, Rihee; Tokuda, Sadahisa; Kamada, Kyousuke

2016-08-01

OBJECT The revascularization technique, including bypass created using the external carotid artery (ECA), radial artery (RA), and M2 portion of middle cerebral artery (MCA), has remained indispensable for treatment of complex aneurysms. To date, it remains unknown whether diameters of the RA, superficial temporal artery (STA), and C2 portion of the internal carotid artery (ICA) and intraoperative MCA blood pressure have influences on the outcome and the symptomatic watershed infarction (WI). The aim of the present study was to evaluate the factors for the symptomatic WI and neurological worsening in patients treated by ECA-RA-M2 bypass for complex ICA aneurysm with therapeutic ICA occlusion. METHODS The authors measured the sizes of vessels (RA, C2, M2, and STA) and intraoperative MCA blood pressure (initial, after ICA occlusion, and after releasing the RA graft bypass) in 37 patients. Symptomatic WI was defined as presence of the following: postoperative new neurological deficits, WI on postoperative diffusion-weighted imaging, and ipsilateral cerebral blood flow reduction on SPECT. Neurological worsening was defined as the increase in 1 or more modified Rankin Scale scores. First, the authors performed receiver operating characteristic curve analysis for continuous variables and the binary end point of the symptomatic WI. The clinical, radiological, and physiological characteristics of patients with and without the symptomatic WI were compared using the log-rank test. Then, the authors compared the variables between patients with and without neurological worsening at discharge and at the 12-month follow-up examination or last hospital visit. RESULTS Symptomatic WI was observed in 2 (5.4%) patients. The mean MCA pressure after releasing the RA graft (< 55 mm Hg; p = 0.017), mean (MCA pressure after releasing the RA graft)/(initial MCA pressure) (< 0.70 mm Hg; p = 0.032), and mean cross-sectional area ratio ([RA/C2 diameter](2) < 0.40 mm [p < 0.0001] and [STA/C2

Increased Intracranial Pressure in the Setting of Enterovirus and Other Viral Meningitides.

PubMed

Beal, Jules C

2017-01-01

Increased intracranial pressure due to viral meningitis has not been widely discussed in the literature, although associations with Varicella and rarely Enterovirus have been described. Patients with increased intracranial pressure and cerebrospinal fluid analysis suggestive of a viral process are sometimes classified as having atypical idiopathic intracranial hypertension (IIH). However, a diagnosis of IIH requires normal cerebrospinal fluid, and therefore in these cases an infection with secondary intracranial hypertension may be a more likely diagnosis. Here seven patients are presented with elevated intracranial pressure and cerebrospinal fluid suggestive of viral or aseptic meningitis. Of these, 1 had Enterovirus and the remainder were diagnosed with nonspecific viral meningitis. These data suggest that viral meningitis may be associated with elevated intracranial pressure more often than is commonly recognized. Enterovirus has previously been associated with increased intracranial pressure only in rare case reports.

[Genetic dissection of intracranial aneurysm].

PubMed

Onda, Hideaki; Yoneyama, Taku; Akagawa, Hiroyuki; Kasuya, Hidetoshi

2008-11-01

Subarachnoid hemorrhage (SAH) due to rupture of an intracranial aneurysm (IA) is a devastating condition with high mortality and morbidity. Genetic as well as environment factors play important roles in the pathogenesis of SAH and IAs. We review the present knowledge on the genetic factors responsible for SAH or IAs. Linkage analysis and association study are used for genetic dissection. Genome-wide linkage analyses have specified several genetic loci for IAs and 6 loci (1p34-36, 7q11, 11q24-25, 14q22-31, 19q13, and Xp22) have been replicated in different populations. Numerous functional and/or positional candidate genes for IAs have been investigated by case-control association studies. The results of genetic association studies are modest because of small sample sizes. To date, no specific genes have been identified as responsible for IA development or rupture. Recent, large-scale genome-wide association (GWA) studies have revealed consistent and replicable genetic markers of several complex diseases such as coronary artery disease and type 2 diabetes. Although, thus far, no GWA studies have been performed for IAs, such a study may accomplish the breakthrough of genetic dissection of IAs. The identification of susceptible genes might lead to the understanding of the mechanism of IA formation or rupture and to novel therapeutic strategies.

The major influence of the atmosphere on intracranial pressure: an observational study.

PubMed

Herbowski, Leszek

2017-01-01

The impact of the atmosphere on human physiology has been studied widely within the last years. In practice, intracranial pressure is a pressure difference between intracranial compartments and the surrounding atmosphere. This means that gauge intracranial pressure uses atmospheric pressure as its zero point, and therefore, this method of pressure measurement excludes the effects of barometric pressure's fluctuation. The comparison of these two physical quantities can only take place through their absolute value relationship. The aim of this study is to investigate the direct effect of barometric pressure on the absolute intracranial pressure homeostasis. A prospective observational cross-sectional open study was conducted in Szczecin, Poland. In 28 neurosurgical patients with suspected normal-pressure hydrocephalus, intracranial intraventricular pressure was monitored in a sitting position. A total of 168 intracranial pressure and atmospheric pressure measurements were performed. Absolute atmospheric pressure was recorded directly. All values of intracranial gauge pressure were converted to absolute pressure (the sum of gauge intracranial pressure and local absolute atmospheric pressure). The average absolute mean intracranial pressure in the patients is 1006.6 hPa (95 % CI 1004.5 to 1008.8 hPa, SEM 1.1), and the mean absolute atmospheric pressure is 1007.9 hPa (95 % CI 1006.3 to 1009.6 hPa, SEM 0.8). The observed association between atmospheric and intracranial pressure is strongly significant (Spearman correlation r = 0.87, p < 0.05) and all the measurements are perfectly reliable (Bland-Altman coefficient is 4.8 %). It appears from this study that changes in absolute intracranial pressure are related to seasonal variation. Absolute intracranial pressure is shown to be impacted positively by atmospheric pressure.

Diagnostic and prognostic value of procalcitonin for early intracranial infection after craniotomy

PubMed Central

Yu, Y.; Li, H.J.

2017-01-01

Intracranial infection is a common clinical complication after craniotomy. We aimed to explore the diagnostic and prognostic value of dynamic changing procalcitonin (PCT) in early intracranial infection after craniotomy. A prospective study was performed on 93 patients suspected of intracranial infection after craniotomy. Routine peripheral venous blood was collected on the day of admission, and C reactive protein (CRP) and PCT levels were measured. Cerebrospinal fluid (CSF) was collected for routine biochemical, PCT and culture assessment. Serum and CSF analysis continued on days 1, 2, 3, 5, 7, 9, and 11. The patients were divided into intracranial infection group and non-intracranial infection group; intracranial infection group was further divided into infection controlled group and infection uncontrolled group. Thirty-five patients were confirmed with intracranial infection after craniotomy according to the diagnostic criteria. The serum and cerebrospinal fluid PCT levels in the infected group were significantly higher than the non-infected group on day 1 (P<0.05, P<0.01). The area under curve of receiver operating characteristics was 0.803 for CSF PCT in diagnosing intracranial infection. The diagnostic sensitivity and specificity of CSF PCT was superior to other indicators. The serum and CSF PCT levels have potential value in the early diagnosis of intracranial infection after craniotomy. Since CSF PCT levels have higher sensitivity and specificity, dynamic changes in this parameter could be used for early detection of intracranial infection after craniotomy, combined with other biochemical indicators. PMID:28443989

Secondary intracranial neoplasia in the dog: 177 cases (1986-2003).

PubMed

Snyder, J M; Lipitz, L; Skorupski, K A; Shofer, F S; Van Winkle, T J

2008-01-01

This study investigates the frequency, location, and clinical findings associated with 177 secondary brain tumors in dogs. Secondary intracranial neoplasia is more common than primary intracranial neoplasia in dogs during the time period studied, and hemangiosarcoma (HSA) is the most common secondary intracranial tumor. One hundred and seventy-seven client-owned dogs presented to the Matthew J. Ryan Veterinary Hospital between 1986 and 2003. Medical records were searched for a diagnosis of intracranial neoplasia in dogs who underwent complete postmortem examination. Of these dogs, those with a diagnosis of primary intracranial neoplasia were excluded. Of the 177 secondary brain tumors, 51 (29%) were HSAs, 44 (25%) were pituitary tumors, 21 (12%) were lymphosarcomas, and 21 (12%) were metastatic carcinomas. The average age at diagnosis was 9.6 +/- 3.0 years. Most tumors were located in the cerebrum, and a mentation change was the most common presenting clinical sign. On postmortem examination, the same tumor that was in the brain was also present in the lung in 84 cases (47%), in the kidney in 62 cases (35%), and in the heart in 55 cases (31%). Secondary intracranial neoplasia in dogs was more common than primary intracranial neoplasia during the time period studied. Many of these dogs had related disease in other body systems that was apparent on diagnostic tests such as thoracic radiography.

Prediction of early neurological deterioration using diffusion- and perfusion-weighted imaging in hyperacute middle cerebral artery ischemic stroke.

PubMed

Arenillas, Juan F; Rovira, Alex; Molina, Carlos A; Grivé, Elisenda; Montaner, Joan; Alvarez-Sabín, José

2002-09-01

Early neurological deterioration (END) occurs in approximately one third of all ischemic stroke patients and is associated with a poor outcome. Our study sought to assess the value of ultra-early MRI in the prediction of END in stroke patients. Between August 1999 and November 2001, 38 stroke patients with a proven middle cerebral artery (MCA) or intracranial internal carotid artery (ICA) occlusion on MR angiography underwent perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI) within 6 hours after onset, and 30 fulfilled all inclusion criteria. Control DWI and MR angiography were performed between days 3 and 5. Cranial CT was performed to rule out hemorrhagic transformation. Vascular risk factors, temperature, blood pressure, glycemia, and blood count were assessed on admission. National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and at 6, 12, 24, and 48 hours. At the same time points, transcranial Doppler (TCD) examinations were conducted to assess arterial recanalization. END was defined as an increase in the NIHSS score >4. A logistic regression model was applied to detect independent predictors of END. The Kruskal-Wallis test was used to evaluate the relationship between infarct growth and duration of vessel occlusion. Initial MR angiography showed an occlusion of intracranial ICA in 7 patients (23.3%), of proximal MCA in 14 (46.6%), and of distal MCA in the remaining 9 (30%). A PWI-DWI mismatch >20% was observed in 28 patients (93.3%). END occurred in 7 patients (23.3%). Baseline NIHSS score (P=0.05), proximal site of occlusion (P=0.002), initial DWI (P=0.002) and PWI (P=0.003) volumes, and reduced PWI-DWI mismatch (P=0.038) were associated with END in the univariate analysis. Only hyperacute DWI volume remained as a predictor of END when a logistic regression model was applied (odds ratio, 11.5; 95% CI, 2.31 to 57.10; P=0.0028). A receiver operator characteristic curve identified a cutoff point of DWI >89 cm(3

21 CFR 882.1620 - Intracranial pressure monitoring device.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Intracranial pressure monitoring device. 882.1620 Section 882.1620 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Diagnostic Devices § 882.1620 Intracranial...

21 CFR 882.1620 - Intracranial pressure monitoring device.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Intracranial pressure monitoring device. 882.1620 Section 882.1620 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Diagnostic Devices § 882.1620 Intracranial...

Endoscopic intracranial surgery enhanced by electromagnetic-guided neuronavigation in children.

PubMed

Hermann, Elvis J; Esmaeilzadeh, Majid; Ertl, Philipp; Polemikos, Manolis; Raab, Peter; Krauss, Joachim K

2015-08-01

Navigated intracranial endoscopy with conventional technique usually requires sharp head fixation. In children, especially in those younger than 1 year of age and in older children with thin skulls due to chronic hydrocephalus, sharp head fixation is not possible. Here, we studied the feasibility, safety, and accuracy of electromagnetic (EM)-navigated endoscopy in a series of children, obviating the need of sharp head fixation. Seventeen children (ten boys, seven girls) between 12 days and 16.8 years (mean age 4.3 years; median 14 months) underwent EM-navigated intracranial endoscopic surgery based on 3D MR imaging of the head. Inclusion criteria for the study were intraventricular cysts, arachnoid cysts, aqueduct stenosis for endoscopic third ventriculostomy (ETV) with distorted ventricular anatomy, the need of biopsy in intraventricular tumors, and multiloculated hydrocephalus. A total of 22 endoscopic procedures were performed. Patients were registered for navigation by surface rendering in the supine position. After confirming accuracy, they were repositioned for endoscopic surgery with the head fixed slightly on a horseshoe headholder. EM navigation was performed using a flexible stylet introduced into the working channel of a rigid endoscope. Neuronavigation accuracy was checked for deviations measured in millimeters on screenshots after the referencing procedure and during surgery in the coronal (z = vertical), axial (x = mediolateral), and sagittal (y = anteroposterior) planes. EM-navigated endoscopy was feasible and safe. In all 17 patients, the aim of endoscopic surgery was achieved, except in one case in which a hemorrhage occurred, blurring visibility, and we proceeded with open surgery without complications for the patient. Navigation accuracy for extracranial markers such as the tragus, bregma, and nasion ranged between 1 and 2.5 mm. Accuracy for fixed anatomical structures like the optic nerve or the carotid artery varied between 2 and 4

Adipsic diabetes insipidus revealing a bifocal intracranial germinoma.

PubMed

Kreutz, Julie; Potorac, Iulia; Lutteri, Laurence; Gennigens, Christine; Martin, Didier; Daly, Adrian F; Bonneville, Jean-Francois; Tshibanda, Luaba; Beckers, Albert

2017-07-01

Adipsic diabetes insipidus is a rare complication of intracranial tumors in which impaired antidiuretic hormone secretion is associated with the loss of thirst sensation. Here, we present the case of a patient with bifocal intracranial germinoma, diagnosed due to symptoms mainly caused by adipsic diabetes insipidus. This is, to our knowledge, the first case of adipsic diabetes insipidus revealing an intracranial germinoma reported in the literature. We describe the diagnostic procedures and the three-year follow-up of this patient. Management of intracranial germ-cell tumors is made complex by the wide range of histological features. Although germinomas have a generally better prognosis than most nongerminomatous tumors, they can have severe or even life-threatening presentations. Adipsic diabetes insipidus is one such severe presentation and its rarity can make it difficult to recognize and manage. Awareness of this potential entity is therefore important for clinical practice. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Pontine hyperperfusion in sporadic hyperekplexia

PubMed Central

Vetrugno, Roberto; Mascalchi, Mario; Vella, Alessandra; Nave, Riccardo Della; Guerrini, Laura; Vattimo, Angelo; del Giudice, Emanuele Miraglia; Plazzi, Giuseppe; D'Angelo, Roberto; Greco, Giovanni; Montagna, Pasquale

2007-01-01

Objective To explore with neuroimaging techniques the anatomical and functional correlates of sporadic hyperekplexia. Methods Two elderly women with sporadic hyperekplexia underwent neurophysiological assessment, MRI of the brain and proton magnetic resonance spectroscopy (1H‐MRS) of the brainstem and frontal lobes. Regional cerebral blood flow was investigated with single photon emission tomography (SPECT) during evoked startles and at rest. Results Both patients showed excessively large and non‐habituating startle responses. In both patients, MRI showed impingement of the brainstem by the vertebrobasilar artery, lack of frontal or brainstem abnormalities on 1H‐MRS and hyperperfusion in the dorsal pons and cingulate cortex, and superior frontal gyrus at SPECT during evoked startles. Conclusions In our patients with hyperekplexia, the vertebrobasilar arteries were found to impinge on the brainstem. Neurophysiological findings and neurofunctional imaging of evoked startles indicated a pontine origin of the movement disorder modulated by activation in cortical, especially frontal, areas. The neurofunctional correlates of evoked startles in human sporadic hyperekplexia are similar to those observed for the startle circuit in animals. PMID:17702784

Pontine hyperperfusion in sporadic hyperekplexia.

PubMed

Vetrugno, Roberto; Mascalchi, Mario; Vella, Alessandra; Della Nave, Riccardo; Guerrini, Laura; Vattimo, Angelo; del Giudice, Emanuele Miraglia; Plazzi, Giuseppe; D'Angelo, Roberto; Greco, Giovanni; Montagna, Pasquale

2007-09-01

To explore with neuroimaging techniques the anatomical and functional correlates of sporadic hyperekplexia. Two elderly women with sporadic hyperekplexia underwent neurophysiological assessment, MRI of the brain and proton magnetic resonance spectroscopy (1H-MRS) of the brainstem and frontal lobes. Regional cerebral blood flow was investigated with single photon emission tomography (SPECT) during evoked startles and at rest. Both patients showed excessively large and non-habituating startle responses. In both patients, MRI showed impingement of the brainstem by the vertebrobasilar artery, lack of frontal or brainstem abnormalities on 1H-MRS and hyperperfusion in the dorsal pons and cingulate cortex, and superior frontal gyrus at SPECT during evoked startles. In our patients with hyperekplexia, the vertebrobasilar arteries were found to impinge on the brainstem. Neurophysiological findings and neurofunctional imaging of evoked startles indicated a pontine origin of the movement disorder modulated by activation in cortical, especially frontal, areas. The neurofunctional correlates of evoked startles in human sporadic hyperekplexia are similar to those observed for the startle circuit in animals.

Rheoencephalography in Meniere's disease

NASA Technical Reports Server (NTRS)

Nikolayev, M. P.; Mertsalova, O. N.

1980-01-01

Rheoencephalography (REG) was used on 35 patients with Meniere's disease to determine tonus and perfusion of cerebral vessels. The analysis took account of age, duration of the disease and presence or absence of cervical osteochondrosis. Hypertensive symptoms in the vertebro-basilar system predominated in the under 45 age group, while for the over 45 patients and those suffering for more than 5 years, hypertensive symptoms were likewise noted in the internal carotid arterial system. Signs of angiospasm were revealed both for patients with cervical osteochondrosis and without it. Hypertensive signs were noted in 88.5% of patients with Meniere's disease and as a rule they were noted in the entire vertebro-basilar system without respect to the presence or absence of concurrent cervical osteochondrosis and uni- or bilateral affection of the labyrinth; in patients over 45 who had suffered more than 5 years this also applied to the internal carotid arterial system. Identification of the condition of cerebral circulation and the planning of more effective therapy that influences vascular tone is made possible by REG.

Multifocal lymphangioendotheliomatosis with devastating intracranial hemorrhage.

PubMed

Huang, Christina; Rizk, Elias; Iantosca, Mark; Zaenglein, Andrea L; Helm, Klaus F; Choudhary, Arabinda K; Dias, Mark S

2013-11-01

An in utero female was found to have a small hemorrhage at the foramen of Monro, hydrocephalus, and what was originally interpreted as a Dandy-Walker variant. At birth she had macrocephaly and numerous cutaneous, multifocal, red-pink blanchable macules. Postnatal MRI demonstrated a hemorrhagic soft-tissue mass involving the upper brainstem, thalamus, and basal ganglia most consistent with in utero complex multifocal intracranial hemorrhage. The skin lesions were thought to be consistent with multifocal lymphangioendotheliomatosis with thrombocytopenia (MLT). The size and location of the hemorrhage precluded operative intervention, although the hydrocephalus was treated with a ventricular shunt. The child continues to have severe developmental delays. Multifocal lymphangioendotheliomatosis with thrombocytopenia is a multifocal vascular disorder most commonly involving the skin and gastrointestinal tract. Intracranial hemorrhages are rare in this context. This case is the third reported instance of MLT with associated intracranial hemorrhage and the only case described in the neurosurgical literature. The authors review the presenting features and pathophysiology of this condition.

Highly accelerated intracranial 4D flow MRI: evaluation of healthy volunteers and patients with intracranial aneurysms.

PubMed

Liu, Jing; Koskas, Louise; Faraji, Farshid; Kao, Evan; Wang, Yan; Haraldsson, Henrik; Kefayati, Sarah; Zhu, Chengcheng; Ahn, Sinyeob; Laub, Gerhard; Saloner, David

2018-04-01

To evaluate an accelerated 4D flow MRI method that provides high temporal resolution in a clinically feasible acquisition time for intracranial velocity imaging. Accelerated 4D flow MRI was developed by using a pseudo-random variable-density Cartesian undersampling strategy (CIRCUS) with the combination of k-t, parallel imaging and compressed sensing image reconstruction techniques (k-t SPARSE-SENSE). Four-dimensional flow data were acquired on five healthy volunteers and eight patients with intracranial aneurysms using CIRCUS (acceleration factor of R = 4, termed CIRCUS4) and GRAPPA (R = 2, termed GRAPPA2) as the reference method. Images with three times higher temporal resolution (R = 12, CIRCUS12) were also reconstructed from the same acquisition as CIRCUS4. Qualitative and quantitative image assessment was performed on the images acquired with different methods, and complex flow patterns in the aneurysms were identified and compared. Four-dimensional flow MRI with CIRCUS was achieved in 5 min and allowed further improved temporal resolution of <30 ms. Volunteer studies showed similar qualitative and quantitative evaluation obtained with the proposed approach compared to the reference (overall image scores: GRAPPA2 3.2 ± 0.6; CIRCUS4 3.1 ± 0.7; CIRCUS12 3.3 ± 0.4; difference of the peak velocities: -3.83 ± 7.72 cm/s between CIRCUS4 and GRAPPA2, -1.72 ± 8.41 cm/s between CIRCUS12 and GRAPPA2). In patients with intracranial aneurysms, the higher temporal resolution improved capturing of the flow features in intracranial aneurysms (pathline visualization scores: GRAPPA2 2.2 ± 0.2; CIRCUS4 2.5 ± 0.5; CIRCUS12 2.7 ± 0.6). The proposed rapid 4D flow MRI with a high temporal resolution is a promising tool for evaluating intracranial aneurysms in a clinically feasible acquisition time.

Intracranial Pressure Monitoring in Infants and Young Children With Traumatic Brain Injury.

PubMed

Dixon, Rebecca R; Nocera, Maryalice; Zolotor, Adam J; Keenan, Heather T

2016-11-01

To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001. Prospective, observational cohort study. Twelve PICUs in North Carolina. All children 24 months old or younger with traumatic brain injury, admitted to an included PICU. None. The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies. Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old

High Prevalence of Multiple Arterial Bed Lesions in Patients With Fibromuscular Dysplasia: The ARCADIA Registry (Assessment of Renal and Cervical Artery Dysplasia).

PubMed

Plouin, Pierre-François; Baguet, Jean-Philippe; Thony, Frédéric; Ormezzano, Olivier; Azarine, Arshid; Silhol, François; Oppenheim, Catherine; Bouhanick, Béatrice; Boyer, Louis; Persu, Alexandre; Hammer, Frank; Gosse, Philippe; Mounier-Vehier, Claire; Le Hello, Claire; Jeunemaitre, Xavier; Azizi, Michel; Amar, Laurence; Chatellier, Gilles; Mousseaux, Elie; Touzé, Emmanuel

2017-09-01

Fibromuscular dysplasia (FMD) commonly affects the renal and cervical arteries but has been described to affect other vascular beds as well. The prevalence of and clinical characteristics associated with multisite FMD (string-of-beds or focal stenoses affecting at least 2 vascular beds) are not known. In the prospective ARCADIA registry (Assessment of Renal and Cervical Artery Dysplasia), symptomatic patients with renal artery (RA) FMD underwent tomographic- or magnetic resonance-angiography from the aortic arch to the intracranial arteries and those with cervical FMD from the diaphragm to the pelvis. Of 469 patients (84.0% women), 225 (48.0%) had multisite FMD. In addition, 86 of 244 patients with single-site disease had dissections or aneurisms affecting other vascular beds, totaling 311 patients (66.3%) with lesions in >1 vascular bed. Among patients with a cerebrovascular presentation, the prevalence of RA lesions was higher in patients with than in those without hypertension (odds ratio, 3.4; 95% confidence interval, 1.99-6.15). Among patients with a renal presentation, the prevalence of cervical lesions was higher in patients with bilateral than in those with unilateral RA lesions (odds ratio, 1.9; 95% confidence interval, 0.99-3.57). In conclusion, FMD is a systemic arterial disease. At least 2 vascular beds were affected by dysplastic stenoses in 48.0% of cases and by dysplastic stenoses, aneurysms, and dissections in 66.1% of cases. RA imaging should be proposed to hypertensive patients with a cerebrovascular presentation. Cervical artery imaging should be considered in patients with a renal presentation and bilateral RA lesions. URL: www.Clinicaltrials.gov. Unique identifier: NCT02884141. © 2017 American Heart Association, Inc.

Penetration of intra-arterially administered vincristine in experimental brain tumor1,2

PubMed Central

Boyle, Frances M.; Eller, Susan L.; Grossman, Stuart A.

2004-01-01

Vincristine is an integral part of the “PCV” regimen that is commonly administered to treat primary brain tumors. The efficacy of vincristine as a single agent in these tumors has been poorly studied. This study was designed to determine whether vincristine enters normal rat brain or an intracranially or subcutaneously implanted glioma and to assess the presence of the efflux pump P-glycoprotein (P-gp) on tumor and vascular endothelial cells. The 9L rat gliosarcoma was implanted intracranially and subcutaneously in three Fischer 344 rats. On day 7, [3H]vincristine (50 μCi, 4.8 μg) was injected into the carotid artery, and the animals were euthanized 10 or 20 min later. Quantitative autoradiography revealed that vincristine levels in the liver were 6- to 11-fold greater than in the i.c. tumor, and 15- to 37-fold greater than in normal brain, the reverse of the expected pattern with intra-arterial delivery. Vincristine levels in the s.c. tumor were 2-fold higher than levels in the i.c. tumor. P-gp was detected with JSB1 antibody in vascular endothelium of both normal brain and the i.c. tumor, but not in the tumor cells in either location, or in endothelial cells in the s.c. tumor. These results demonstrate that vincristine has negligible penetration of normal rat brain or i.c. 9L glioma despite intra-arterial delivery and the presence of blood-brain barrier dysfunction as demonstrated by Evan’s blue. Furthermore, this study suggests that P-gp-mediated efflux from endothelium may explain these findings. The lack of penetration of vincristine into brain tumor and the paucity of single-agent activity studies suggest that vincristine should not be used in the treatment of primary brain tumors. PMID:15494097

Optoacoustic detection and monitoring of blast-induced intracranial hematomas in rats

NASA Astrophysics Data System (ADS)

Petrov, Andrey; Wynne, Karon E.; Prough, Donald S.; Dewitt, Douglas S.; Petrov, Yuriy; Petrov, Irene Y.; Parsley, Margaret A.; Esenaliev, Rinat O.

2014-03-01

Patients with acute intracranial hematomas often require surgical drainage within the first four hours after traumatic brain injury (TBI) to avoid death or severe neurologic disability. CT and MRI permit rapid, noninvasive diagnosis of hematomas, but can be used only at a major health-care facility. At present, there is no device for noninvasive detection and characterization of hematomas in pre-hospital settings. We proposed to use an optoacoustic technique for rapid, noninvasive diagnosis and monitoring of hematomas, including intracranial hematomas. Unlike bulky CT and MR equipment, an optoacoustic system can be small and easily transported in an emergency vehicle. In this study we used a specially-designed blast device to inflict TBI in rats. A near-infrared OPO-based optoacoustic system developed for hematoma diagnosis and for blood oxygenation monitoring in the superior sagittal sinus (SSS) in small animals was used in the study. Optoacoustic signals recorded simultaneously from the SSS and hematomas allowed for measurements of their oxygenations. The presence of hematomas was confirmed after the experiment in gross pictures of the exposed brains. After blast the hematoma signal and oxygenation increased, while SSS oxygenation decreased due to the blastinduced TBI. The increase of the oxygenation in fresh hematomas may be explained by the leakage of blood from arteries which have higher blood pressure compared to that of veins. These results indicate that the optoacoustic technique can be used for early diagnosis of hematomas and may provide important information for improving outcomes in patients with TBI or stroke (both hemorrhagic and ischemic).

Ruptured posterior ethmoidal artery aneurysm and Moyamoya disease in an adult patient. Case report.

PubMed

Mélot, A; Chazot, J-V; Troude, L; De la Rosa, S; Brunel, H; Roche, P-H

2016-06-01

The association between Moyamoya disease and intracranial aneurysms is well described. In our case, we describe a unique aneurismal location and its management. We report the case of a 74-year-old woman affected by a Moyamoya disease who displayed a frontal lobe hematoma. The origin of the bleeding came from the rupture of a posterior ethmoidal artery aneurysm that was treated surgically with favourable outcome. This case of a ruptured posterior ethmoidal artery aneurysm in a Moyamoya patient illustrates the polymorphism of the vascular complications encountered in this disease. It stresses the need to obtain information from an angiographic investigation in order to select the best therapeutic option and to reduce procedural complications. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Audiovestibular impairments associated with intracranial hypotension.

PubMed

Choi, Jae-Hwan; Cho, Kee-Yong; Cha, Seung-Yi; Seo, Jae-Deuk; Kim, Min-Ji; Choi, Yu Ri; Kim, Sung-Hee; Kim, Ji-Soo; Choi, Kwang-Dong

2015-10-15

To investigate the patterns and mechanisms of audiovestibular impairments associated with intracranial hypotension. We had consecutively recruited 16 patients with intracranial hypotension at the Neurology Center of Pusan National University Hospital for two years. Spontaneous, gaze-evoked, and positional nystagmus were recorded using 3D video-oculography in all patients, and the majority of them also had pure tone audiometry and bithermal caloric tests. Of the 16 patients, five (31.3%) reported neuro-otological symptoms along with the orthostatic headache while laboratory evaluation demonstrated audiovestibular impairments in ten (62.5%). Oculographic analyses documented spontaneous and/or positional nystagmus in six patients (37.5%) including weak spontaneous vertical nystagmus with positional modulation (n=4) and pure positional nystagmus (n=2). One patient presented with recurrent spontaneous vertigo and tinnitus mimicking Meniere's disease, and showed unidirectional horizontal and torsional nystagmus with normal head impulse tests during the attacks. Bithermal caloric tests were normal in all nine patients tested. Audiometry showed unilateral (n=6) or bilateral (n=1) sensorineural hearing loss in seven (53.8%) of the 13 patients tested. Intracranial hypotension frequently induces audiovestibular impairments. In addition to endolymphatic hydrops and irritation of the vestibulocochlear nerve, compression or traction of the brainstem or cerebellum due to loss of CSF buoyancy may be considered as a mechanism of frequent spontaneous or positional vertical nystagmus in patients with intracranial hypotension. Copyright © 2015 Elsevier B.V. All rights reserved.

Idiopathic intracranial hypertension and sickle cell disease: two case reports.

PubMed

Segal, Laura; Discepola, Marino

2005-12-01

Two patients with sickle cell disease presented with headaches and visual disturbances, typical complaints of this disorder. However, prompt diagnosis of idiopathic intracranial hypertension and initiation of medical therapy lead to improved symptoms and restored vision. Ophthalmologists should consider sickle cell disease to be an independent risk factor for idiopathic intracranial hypertension when a patient is being assessed for visual disturbances. Although a rare condition, idiopathic intracranial hypertension has several key signs useful in establishing a diagnosis. It is critical to recognize the warning signs and symptoms to prevent devastating ophthalmologic complications. We report the first cases of idiopathic intracranial hypertension in patients with the novel Quebec-Chori beta-chain variant of sickle cell disease.

Current Treatment Strategies for Intracranial Aneurysms: An Overview

PubMed Central

Lin, Hao; Summers, Richard; Yang, Mingmin; Cousins, Brian G.

2017-01-01

Intracranial aneurysm is a leading cause of stroke. Its treatment has evolved over the past 2 decades. This review summarizes the treatment strategies for intracranial aneurysms from 3 different perspectives: open surgery approach, transluminal treatment approach, and new technologies being used or trialed. We introduce most of the available treatment techniques in detail, including contralateral clipping, wrapping and clipping, double catheters assisting coiling and waffle-cone technique, and so on. Data from major trials such as Analysis of Treatment by Endovascular approach of Non-ruptured Aneurysms (ATENA), Internal Subarachnoid Trial (ISAT), Clinical and Anatomical Results in the Treatment of Ruptured Intracranial Aneurysms (CLARITY), and Barrow Ruptured Aneurysm Trial (BRAT) as well as information from other clinical reports and local experience are reviewed to suggest a clinical pathway for treating different types of intracranial aneurysms. It will be a valuable supplement to the current existing guidelines. We hope it could help assisting real-time decision-making in clinical practices and also encourage advancements in managing the disease. PMID:28355880

Evaluation of Optical Coherence Tomography to Detect Elevated Intracranial Pressure in Children.

PubMed

Swanson, Jordan W; Aleman, Tomas S; Xu, Wen; Ying, Gui-Shuang; Pan, Wei; Liu, Grant T; Lang, Shih-Shan; Heuer, Gregory G; Storm, Phillip B; Bartlett, Scott P; Katowitz, William R; Taylor, Jesse A

2017-04-01

Detecting elevated intracranial pressure in children with subacute conditions, such as craniosynostosis or tumor, may enable timely intervention and prevent neurocognitive impairment, but conventional techniques are invasive and often equivocal. Elevated intracranial pressure leads to structural changes in the peripapillary retina. Spectral-domain (SD) optical coherence tomography (OCT) can noninvasively quantify retinal layers to a micron-level resolution. To evaluate whether retinal measurements from OCT can serve as an effective surrogate for invasive intracranial pressure measurement. This cross-sectional study included patients undergoing procedures at the Children's Hospital of Philadelphia from September 2014 to June 2015. Three groups of patients (n = 79) were prospectively enrolled from the Craniofacial Surgery clinic including patients with craniosynostosis (n = 40). The positive control cohort consisted of patients with hydrocephalus and suspected intracranial hypertension (n = 5), and the negative control cohort consisted of otherwise healthy patients undergoing a minor procedure (n = 34). Spectral-domain OCT was performed preoperatively in all cohorts. Children with cranial pathology, but not negative control patients, underwent direct intraoperative intracranial pressure measurement. The primary outcome was the association between peripapillary retinal OCT parameters and directly measured elevated intracranial pressure. The mean (SD) age was 34.6 (45.2) months in the craniosynostosis cohort (33% female), 48.9 (83.8) months in the hydrocephalus and suspected intracranial hypertension cohort (60% female), and 59.7 (64.4) months in the healthy cohort (47% female). Intracranial pressure correlated with maximal retinal nerve fiber layer thickness (r = 0.60, P ≤ .001), maximal retinal thickness (r = 0.53, P ≤ .001), and maximal anterior retinal projection (r = 0.53, P = .003). Using cut points derived from the

Randomized controlled trial comparing cerebral perfusion pressure-targeted therapy versus intracranial pressure-targeted therapy for raised intracranial pressure due to acute CNS infections in children.

PubMed

Kumar, Ramesh; Singhi, Sunit; Singhi, Pratibha; Jayashree, Muralidharan; Bansal, Arun; Bhatti, Anuj

2014-08-01

In children with acute CNS infection, management of raised intracranial pressure improves mortality and neuromorbidity. We compared cerebral perfusion pressure-targeted approach with the conventional intracranial pressure-targeted approach to treat raised intracranial pressure in these children. Prospective open-label randomized controlled trial. PICU in a tertiary care academic institute. Hundred ten children (1-12 yr) with acute CNS infections having raised intracranial pressure and a modified Glasgow Coma Scale score less than or equal to 8 were enrolled. Patients were randomized to receive either cerebral perfusion pressure-targeted therapy (n = 55) (maintaining cerebral perfusion pressure ≥ 60 mm Hg, using normal saline bolus and vasoactive therapy-dopamine, and if needed noradrenaline) or intracranial pressure-targeted therapy (n = 55) (maintaining intracranial pressure < 20 mm Hg using osmotherapy while ensuring normal blood pressure). The primary outcome was mortality up to 90 days after discharge from PICU. Secondary outcome was modified Glasgow Coma Scale score at 72 hours after enrollment, length of PICU stay, duration of mechanical ventilation, and hearing deficit and functional neurodisability at discharge and 90-day follow-up. A 90-day mortality in intracranial pressure group (38.2%) was significantly higher than cerebral perfusion pressure group (18.2%; relative risk = 2.1; 95% CI, 1.09-4.04; p = 0.020). The cerebral perfusion pressure group in comparison with intracranial pressure group had significantly higher median (interquartile range) modified Glasgow Coma Scale score at 72 hours (10 [8-11] vs 7 [4-9], p < 0.001), shorter length of PICU stay (13 d [10.8-15.2 d] vs. 18 d [14.5-21.5 d], p = 0.002) and mechanical ventilation (7.5 d [5.4-9.6 d] vs. 11.5 d [9.5-13.5 d], p = 0.003), lower prevalence of hearing deficit (8.9% vs 37.1%; relative risk = 0.69; 95% CI, 0.53-0.90; p = 0.005), and neurodisability at discharge from PICU (53.3% vs. 82

Brain Slump Caused by Jugular Venous Stenoses Treated by Stenting: A Hypothesis to Link Spontaneous Intracranial Hypotension with Idiopathic Intracranial Hypertension

PubMed Central

Higgins, Nicholas; Trivedi, Rikin; Greenwood, Richard; Pickard, John

2015-01-01

Spontaneous intracranial hypotension, of which brain slump is an extreme expression, is caused by a cerebrospinal fluid leak. The reason the leak develops in the first place, however, is unknown, and some cases can be very difficult to manage. We describe a patient with severe symptoms of spontaneous intracranial hypotension and brain slump documented by magnetic resonance imaging whose clinical syndrome and structural brain anomaly resolved completely after treatment directed exclusively at improving cranial venous outflow. Diagnostics included computed tomography (CT) venography, catheter venography, and jugular venoplasty. CT venography showed narrowing of both internal jugular veins below the skull base. Catheter venography confirmed that these were associated with pressure gradients. Jugular venoplasty performed on two separate occasions as a clinical test gave temporary respite. Lasting remission (2 years of follow-up) was achieved by stenting the dominant internal jugular vein. These findings and this outcome suggest a mechanism for the development of spontaneous intracranial hypotension that would link it to idiopathic intracranial hypertension and have cranial venous outflow obstruction as the underlying cause. PMID:26251803

Brain Slump Caused by Jugular Venous Stenoses Treated by Stenting: A Hypothesis to Link Spontaneous Intracranial Hypotension with Idiopathic Intracranial Hypertension.

PubMed

Higgins, Nicholas; Trivedi, Rikin; Greenwood, Richard; Pickard, John

2015-07-01

Spontaneous intracranial hypotension, of which brain slump is an extreme expression, is caused by a cerebrospinal fluid leak. The reason the leak develops in the first place, however, is unknown, and some cases can be very difficult to manage. We describe a patient with severe symptoms of spontaneous intracranial hypotension and brain slump documented by magnetic resonance imaging whose clinical syndrome and structural brain anomaly resolved completely after treatment directed exclusively at improving cranial venous outflow. Diagnostics included computed tomography (CT) venography, catheter venography, and jugular venoplasty. CT venography showed narrowing of both internal jugular veins below the skull base. Catheter venography confirmed that these were associated with pressure gradients. Jugular venoplasty performed on two separate occasions as a clinical test gave temporary respite. Lasting remission (2 years of follow-up) was achieved by stenting the dominant internal jugular vein. These findings and this outcome suggest a mechanism for the development of spontaneous intracranial hypotension that would link it to idiopathic intracranial hypertension and have cranial venous outflow obstruction as the underlying cause.

Effective Intraluminal Shunt in Carotid Endarterectomy for Carotid Artery Near Occlusion: Technical Report.

PubMed

Kawamura, Yoichiro; Maruyama, Daisuke; Akagi, Yojiro; Iihara, Koji

2017-10-01

Carotid artery near occlusion is a critical degree of stenosis whereby blood flow is decreased and the distal cervical and intracranial internal carotid arteries (ICAs) are prone to collapse. Considering the diminished perfusion and risk of progression to total occlusion and periocclusive embolism, we performed carotid endarterectomy for carotid artery near occlusion. Accurate evaluation of tandem stenosis or patency of the poststenotic ICA in carotid artery near occlusion is often difficult preoperatively. Thus we performed carotid endarterectomy in a hybrid operating room where intraoperative digital subtraction angiography (DSA) and endovascular angioplasty or stenting for distal lesions can be performed if necessary. In addition, to evaluate the distal ICA intraoperatively, we used an intraluminal shunt for shunt angiography, with injection of contrast material through the shunt tube, as a replacement for conventional DSA. Furthermore, an intraluminal shunt held the collapsed lumen open and provided a scaffold for suturing, which prevented postoperative stenosis of the distal ICA. The present report is intended to underline the merits of intraluminal shunt as a replacement for conventional DSA and as a scaffold for suturing. Copyright © 2017 Elsevier Inc. All rights reserved.

Duplex ultrasonography for the detection of vertebral artery stenosis: A comparison with CT angiography.

PubMed

Rozeman, Anouk D; Hund, Hajo; Westein, Michel; Wermer, Marieke J H; Lycklama À Nijeholt, Geert J; Boiten, Jelis; Schimsheimer, Robert-Jan; Algra, Ale

2017-08-01

Vertebrobasilar stenosis is frequent in patients with posterior circulation stroke and it increases risk of recurrence. We investigated feasibility of duplex ultrasonography (DUS) for screening for extracranial vertebral artery stenosis and compared it with CT angiography (CTA). We gathered data on 337 consecutive patients who had DUS because of posterior circulation stroke or TIA. Matching CTA studies were retrieved and used as reference. Stenosis on CTA was considered "significant" if >50%, at DUS if Peak Systolic Velocity (PSV) > 140 cm/s for the V1 segment and PSV > 125 cm/s for the V2 segment. We determined the area under the ROC curve (AUROC). In addition, we calculated which PSV cut-off value resulted in highest sensitivity with acceptable specificity. DUS was able to make an adequate measurement in 378 of 674 V1 segments and 673 of 674 V2 segments. DUS detected a significant stenosis in 52 of 378 V1 segments; 12 were confirmed by CTA (AUROC 0.73, 95% Confidence Interval 0.63-0.83). The optimal DUS PSV cut-off value for this segment was 90 cm/s. For the V2 segment there were too few stenoses to allow reliable assessment of diagnostic characteristics of DUS. Although DUS has a fair AUROC for detecting significant stenosis, adequate assessment of the V1 segment is often not possible due to anatomic difficulties. Assessment of the V2 segment is feasible but yielded few stenoses. Hence, we consider usefulness of DUS for screening of extracranial vertebral artery stenosis limited.

Progress in carotid artery surgery at the base of the skull.

PubMed

Sandmann, W; Hennerici, M; Aulich, A; Kniemeyer, H; Kremer, K W

1984-11-01

From 1977 to 1984, 752 reconstructions of the supra-aortic arteries were performed at our service. In a group of 31 patients presenting with transient ischemic attacks (13) or minor strokes (15), preoperative multiplane angiograms identified lesions from various causes in extremely high locations (fibromuscular dysplasia, 10; atherosclerosis, 6; traumatic changes, 10; spontaneous dissection, 3; and mycotic aneurysms and others, 4) in 34 internal carotid arteries (aneurysms, 10; and stenosis, 24). Surgery was performed on 30 patients. Flow restoration was achieved by resection and vein graft replacement (20), gradual dilatation (5), thromboendarterectomy (6), and tangential clip for exclusion of a lateral aneurysm (1). Only one patient was treated with an extracranial-intracranial anastomosis because the stenosis extended into the carotid siphon. One patient was treated with heparin. Exposure of the internal carotid artery (ICA) at the base of the skull required dissection of the digastric muscle, careful mobilization of the cranial nerves, and detachment of the styloid process in 29 patients. Partial resection of the mastoid process was helpful in two patients. The carotid bone canal was opened from the lateral side in four cases to allow the most distal anastomosis 1 cm within the carotid canal. Back-bleeding was controlled by a balloon catheter. A shunt was impossible to use and clamping time averaged 62 +/- 40 minutes. Except for one recurrent stroke and two transient ischemic attacks no other neurologic deficits occurred. Cranial nerve damage could not be avoided in 21 cases (nervus recurrens, 7; nervus glossopharyngeus, 16; and nervus facialis, 4) but disappeared clinically within a 1- to 6-month period in all but two. Each surgical patient underwent control angiography, which demonstrated 30 arteries to be patent, two became occluded, and one had an insignificant stenosis. We conclude that standard surgical techniques are unsuitable for repair of highly

Three-dimensional stereotactic atlas of the extracranial vasculature correlated with the intracranial vasculature, cranial nerves, skull and muscles.

PubMed

Nowinski, Wieslaw L; Shoon Let Thaung, Thant; Choon Chua, Beng; Hnin Wut Yi, Su; Yang, Yili; Urbanik, Andrzej

2015-04-01

Our objective was to construct a 3D, interactive, and reference atlas of the extracranial vasculature spatially correlated with the intracranial blood vessels, cranial nerves, skull, glands, and head muscles.The atlas has been constructed from multiple 3T and 7T magnetic resonance angiogram (MRA) brain scans, and 3T phase contrast and inflow MRA neck scans of the same specimen in the following steps: vessel extraction from the scans, building 3D tubular models of the vessels, spatial registration of the extra- and intracranial vessels, vessel editing, vessel naming and color-coding, vessel simplification, and atlas validation.This new atlas contains 48 names of the extracranial vessels (25 arterial and 23 venous) and it has been integrated with the existing brain atlas.The atlas is valuable for medical students and residents to easily get familiarized with the extracranial vasculature with a few clicks; is useful for educators to prepare teaching materials; and potentially can serve as a reference in the diagnosis of vascular disease and treatment, including craniomaxillofacial surgeries and radiologic interventions of the face and neck. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Jailed double-microcatheter technique following horizontal stenting for coil embolization of intracranial wide-necked bifurcation aneurysms: A technical report of two cases.

PubMed

Kitahara, Takahiro; Hatano, Taketo; Hayase, Makoto; Hattori, Etsuko; Miyakoshi, Akinori; Nakamura, Takehiko

2017-04-01

The horizontal stenting technique facilitates endovascular treatment of wide-necked bifurcation intracranial aneurysms. Previous literature shows, however, that subsequent coil embolization at initial treatment results in incomplete obliteration in many cases. The authors present two consecutive cases of wide-necked large bifurcation aneurysms to describe an additional coil embolization technique following horizontal stenting. The patients were a 53-year-old female with an unruptured internal carotid artery terminus aneurysm and a 57-year-old female with a recurrent basilar artery tip aneurysm. Both patients underwent endovascular treatment with horizontal stenting followed by coil embolization with jailed double-microcatheters. Immediate complete obliteration was achieved with no complications, and no recanalization was observed at the one-year follow-up in both cases. Coil embolization with jailed double-microcatheter technique following horizontal stenting is a safe and effective strategy for wide-necked bifurcation aneurysms.

STA-ACA bypass using the ipsilateral free STA graft as an interposition graft and A3-A3 anastomosis for treatment of bilateral ACA steno-occlusive ischemia.

PubMed

Horiuchi, Tetsuyoshi; Ichinose, Shunsuke; Agata, Masahiro; Ito, Kiyoshi; Hongo, Kazuhiro

2018-04-01

Anterior cerebral artery (ACA)-related ischemia is a rare entity in patients with atherosclerosis. Some surgical treatments are reported to date. We present the modification of intracranial-intracranial and intracranial-extracranial bypasses for symptomatic bilateral ACA steno-occlusive disease. The A3-A3 bypass followed by the superficial temporal artery-ACA bypass using the ipsilateral free superficial temporal artery graft is useful without harvesting of the radial artery. Bilateral ACA steno-occlusive induced ischemia can be treated with tailored bypass procedures.

Three distal anterior cerebral artery aneurysms in the same branch associated with five additional intracranial aneurysms

PubMed Central

Kozyrev, Danil A.; Jahromi, Behnam Rezai; Thiarawat, Peeraphong; Choque-Velasquez, Joham; Ludtka, Christopher; Goehre, Felix; Hernesniemi, Juha

2017-01-01

Background: Multiple distal anterior cerebral artery (DACA) aneurysms appear as rare findings. Simultaneous treatment of such lesions can be particularly challenging. A report of three aneurysms on the same parent artery has not been reported before. We report a case of three DACA aneurysms treated within one microsurgical operation in a patient with eight aneurysms. Case Description: A 62-year-old woman incidentally presented with multiple various size saccular aneurysms, including tree on the left DACA. One of the DACA aneurysm was located on the A3 segment, and the other two were on the A4 and A5 segments. Ligation of all three of these aneurysms was planned in one operation. A standard anterior interhemispheric approach was utilized. Three aneurysms were successfully clipped using four clips. Intraoperative angiography confirmed aneurysm occlusion with parent artery patency preservation. The patient showed no new postoperative neurological deficit. Conclusion: Clipping multiple DACA aneurysms within a single microneurosurgical operation is a feasible treatment option. Meticulous analysis of preoperative imaging features is crucial for selecting the best, patient-specific treatment strategy. PMID:28540128

Biological signatures of asymptomatic extra- and intracranial atherosclerosis: the Barcelona-AsIA (Asymptomatic Intracranial Atherosclerosis) study.

PubMed

López-Cancio, Elena; Galán, Amparo; Dorado, Laura; Jiménez, Marta; Hernández, María; Millán, Mónica; Reverté, Silvia; Suñol, Anna; Barallat, Jaume; Massuet, Anna; Alzamora, Maria Teresa; Dávalos, Antonio; Arenillas, Juan Francisco

2012-10-01

Intracranial atherosclerotic disease (ICAD) remains a challenge for stroke primary and secondary prevention. Molecular pathways involved in the development of ICAD from its asymptomatic stages are largely unknown. In our population-based study, we aimed to compare the risk factor and biomarker profiles associated with intracranial and extracranial asymptomatic cerebral atherosclerosis. The Asymptomatic Intracranial Atherosclerosis (AsIA) study cohort includes a random sample population of 933 white subjects >50 years with a moderate to high vascular risk (based on REGICOR score) and without a history of stroke (64% males; mean age, 66 years). Carotid and intracranial atherosclerosis were screened by cervical and transcranial color-coded Duplex ultrasound, being moderate to severe stenoses confirmed by MR angiography. We registered clinical and anthropometric data and created a biobank with blood samples at baseline. A panel of biomarkers involved in atherothrombogenesis was determined: C-reactive protein, asymmetric-dimethylarginine, resistin, and plasminogen activator inhibitor-1. Insulin resistance was quantified by Homeostasis Model Assessment index. After multinomial regression analyses, male sex, hypertension, smoking, and alcoholic habits were independent risk factors of isolated extracranial atherosclerotic disease. Diabetes and metabolic syndrome conferred a higher risk for ICAD than for extracranial atherosclerotic disease. Moreover, metabolic syndrome and insulin resistance were independent risk factors of moderate to severe ICAD but were not risk factors of moderate to severe extracranial atherosclerotic disease. Regarding biomarkers, asymmetric-dimethylarginine was independently associated with isolated ICAD and resistin with combined ICAD-extracranial atherosclerotic disease. Our findings show distinct clinical and biological profiles in subclinical ICAD and extracranial atherosclerotic disease. Insulin resistance emerged as an important molecular

A hemorrhagic complication after Onyx embolization of a tentorial dural arteriovenous fistula: A caution about subdural extension with pial arterial supply.

PubMed

Sato, Kenichi; Matsumoto, Yasushi; Endo, Hidenori; Tominaga, Teiji

2017-06-01

We report a case of tentorial dural arteriovenous fistula (DAVF) with a severe intracranial hemorrhage occurring after Onyx embolization. A 40-year-old man presented with an asymptomatic tentorial DAVF on angiography. Transarterial embolization with Onyx was performed via the middle meningeal artery, and the cast filled the fistula itself and its proximal draining vein. Postoperative angiography confirmed complete occlusion of the DAVF. A computed tomography scan performed immediately after the procedure demonstrated an acute subdural hematoma with the temporal hemorrhage. Emergency craniotomy revealed continuous arterial bleeding from a viable glomus-like vascular structure around the proximal part of the embolized draining vein, fed by a pial artery arising from the posterior cerebral artery. Pathologic findings suggested diagnosis of vascular malformation extending into the subdural space. Tentorial DAVFs can extend to the subdural space along their drainage route, and may be involved in severe hemorrhagic complications of curative endovascular treatment using Onyx, particularly those with pial arterial supply.

3D printing of intracranial aneurysm based on intracranial digital subtraction angiography and its clinical application.

PubMed

Wang, Jian-Li; Yuan, Zi-Gang; Qian, Guo-Liang; Bao, Wu-Qiao; Jin, Guo-Liang

2018-06-01

The study aimed to develop simulation models including intracranial aneurysmal and parent vessel geometries, as well as vascular branches, through 3D printing technology. The simulation models focused on the benefits of aneurysmal treatments and clinical education. This prospective study included 13 consecutive patients who suffered from intracranial aneurysms confirmed by digital subtraction angiography (DSA) in the Neurosurgery Department of Shaoxing People's Hospital. The original 3D-DSA image data were extracted through the picture archiving and communication system and imported into Mimics. After reconstructing and transforming to Binary STL format, the simulation models of the hollow vascular tree were printed using 3D devices. The intracranial aneurysm 3D printing simulation model was developed based on DSA to assist neurosurgeons in aneurysmal treatments and residency training. Seven neurosurgical residents and 15 standardization training residents received their simulation model training and gave high assessments for the educational course with the follow-up qualitative questionnaire. 3D printed simulation models based on DSA can perfectly reveal target aneurysms and help neurosurgeons select therapeutic strategies precisely. As an educational tool, the 3D aneurysm vascular simulation model is useful for training residents.

Vorticity dynamics in an intracranial aneurysm

NASA Astrophysics Data System (ADS)

Le, Trung; Borazjani, Iman; Sotiropoulos, Fotis

2008-11-01

Direct Numerical Simulation is carried out to investigate the vortex dynamics of physiologic pulsatile flow in an intracranial aneurysm. The numerical solver is based on the CURVIB (curvilinear grid/immersed boundary method) approach developed by Ge and Sotiropoulos, J. Comp. Physics, 225 (2007) and is applied to simulate the blood flow in a grid with 8 million grid nodes. The aneurysm geometry is extracted from MRI images from common carotid artery (CCA) of a rabbit (courtesy Dr.Kallmes, Mayo Clinic). The simulation reveals the formation of a strong vortex ring at the proximal end during accelerated flow phase. The vortical structure advances toward the aneurysm dome forming a distinct inclined circular ring that connects with the proximal wall via two long streamwise vortical structures. During the reverse flow phase, the back flow results to the formation of another ring at the distal end that advances in the opposite direction toward the proximal end and interacts with the vortical structures that were created during the accelerated phase. The basic vortex formation mechanism is similar to that observed by Webster and Longmire (1998) for pulsed flow through inclined nozzles. The similarities between the two flows will be discussed and the vorticity dynamics of an aneurysm and inclined nozzle flows will be analyzed.This work was supported in part by the University of Minnesota Supercomputing Institute.

Outcomes and complications of intracranial pressure monitoring in acute liver failure: a retrospective cohort study.

PubMed

Karvellas, Constantine J; Fix, Oren K; Battenhouse, Holly; Durkalski, Valerie; Sanders, Corron; Lee, William M

2014-05-01

To determine if intracranial pressure monitor placement in patients with acute liver failure is associated with significant clinical outcomes. Retrospective multicenter cohort study. Academic liver transplant centers comprising the U.S. Acute Liver Failure Study Group. Adult critically ill patients with acute liver failure presenting with grade III/IV hepatic encephalopathy (n = 629) prospectively enrolled between March 2004 and August 2011. Intracranial pressure monitored (n = 140) versus nonmonitored controls (n = 489). Intracranial pressure monitored patients were younger than controls (35 vs 43 yr, p < 0.001) and more likely to be on renal replacement therapy (52% vs 38%, p = 0.003). Of 87 intracranial pressure monitored patients with detailed information, 44 (51%) had evidence of intracranial hypertension (intracranial pressure > 25 mm Hg) and overall 21-day mortality was higher in patients with intracranial hypertension (43% vs 23%, p = 0.05). During the first 7 days, intracranial pressure monitored patients received more intracranial hypertension-directed therapies (mannitol, 56% vs 21%; hypertonic saline, 14% vs 7%; hypothermia, 24% vs 10%; p < 0.03 for each). Forty-one percent of intracranial pressure monitored patients received liver transplant (vs 18% controls; p < 0.001). Overall 21-day mortality was similar (intracranial pressure monitored 33% vs controls 38%, p = 0.24). Where data were available, hemorrhagic complications were rare in intracranial pressure monitored patients (4 of 56 [7%]; three died). When stratifying by acetaminophen status and adjusting for confounders, intracranial pressure monitor placement did not impact 21-day mortality in acetaminophen patients (p = 0.89). However, intracranial pressure monitor was associated with increased 21-day mortality in nonacetaminophen patients (odds ratio, ~ 3.04; p = 0.014). In intracranial pressure monitored patients with acute liver failure, intracranial hypertension is commonly observed. The use

Intracranial haemorrhage and use of selective serotonin reuptake inhibitors

PubMed Central

de Abajo, Francisco J; Jick, Hershel; Derby, Laura; Jick, Susan; Schmitz, Stephen

2000-01-01

Aims In the past few years an increasing number of bleeding disorders have been reported in association with the use of selective serotonin reuptake inhibitors (SSRIs), including serious cases of intracranial haemorrhage, raising concerns about the safety of this class of drugs. The present study was performed to test the hypothesis of an increased risk of intracranial haemorrhage associated with the use of SSRIs. Methods We carried out a case-control study nested in a cohort of antidepressants users with the UK-based General Practice Research Database (GPRD) as the primary source of information. The study cohort encompassed subjects aged between 18 and 79 years who received a first-time prescription for any antidepressant from January, 1990 to October, 1997. Patients with presenting conditions or treatments that could be associated with an increased risk of intracranial haemorrhage were excluded from the cohort. Patients were followed-up until the occurrence of an idiopathic intracranial haemorrhage. Up to four controls per case, matched on age, sex, calendar time and practice were randomly selected from the study cohort. We estimated adjusted odds ratios and 95% confidence intervals of intracranial haemorrhage with current use of SSRIs and other antidepressants as compared with nonuse using conditional logistic regression. Results We identified 65 cases of idiopathic intracranial haemorrhage and 254 matched controls. Current exposure to SSRIs was ascertained in 7 cases (10.8%) and 24 controls (9.7%) resulting in an adjusted OR (95%CI) of 0.8 (0.3,2.3). The estimate for ‘other antidepressants’ was 0.7 (0.3,1.6). The effect measures were not modified by gender or age. No effect related to dose or treatment duration was detected. The risk estimates did not change according to the location of bleeding (intracerebral or subarachnoid). Conclusions Our results are not compatible with a major increased risk of intracranial haemorrhage among users of SSRIs or other

Evaluation of Optical Coherence Tomography to Detect Elevated Intracranial Pressure in Children

PubMed Central

Swanson, Jordan W.; Aleman, Tomas S.; Xu, Wen; Ying, Gui-Shuang; Pan, Wei; Liu, Grant T.; Lang, Shih-Shan; Heuer, Gregory G.; Storm, Phillip B.; Bartlett, Scott P.; Katowitz, William R.

2017-01-01

Importance Detecting elevated intracranial pressure in children with subacute conditions, such as craniosynostosis or tumor, may enable timely intervention and prevent neurocognitive impairment, but conventional techniques are invasive and often equivocal. Elevated intracranial pressure leads to structural changes in the peripapillary retina. Spectral-domain (SD) optical coherence tomography (OCT) can noninvasively quantify retinal layers to a micron-level resolution. Objective To evaluate whether retinal measurements from OCT can serve as an effective surrogate for invasive intracranial pressure measurement. Design, Setting, and Participants This cross-sectional study included patients undergoing procedures at the Children’s Hospital of Philadelphia from September 2014 to June 2015. Three groups of patients (n = 79) were prospectively enrolled from the Craniofacial Surgery clinic including patients with craniosynostosis (n = 40). The positive control cohort consisted of patients with hydrocephalus and suspected intracranial hypertension (n = 5), and the negative control cohort consisted of otherwise healthy patients undergoing a minor procedure (n = 34). Main Outcomes and Measures Spectral-domain OCT was performed preoperatively in all cohorts. Children with cranial pathology, but not negative control patients, underwent direct intraoperative intracranial pressure measurement. The primary outcome was the association between peripapillary retinal OCT parameters and directly measured elevated intracranial pressure. Results The mean (SD) age was 34.6 (45.2) months in the craniosynostosis cohort (33% female), 48.9 (83.8) months in the hydrocephalus and suspected intracranial hypertension cohort (60% female), and 59.7 (64.4) months in the healthy cohort (47% female). Intracranial pressure correlated with maximal retinal nerve fiber layer thickness (r = 0.60, P ≤ .001), maximal retinal thickness (r = 0.53, P ≤ .001), and maximal

A case of direct intracranial extension of tuberculous otitis media.

PubMed

Kim, Dong-Kee; Park, Shi-Nae; Park, Kyung-Ho; Yeo, Sang Won

2014-02-01

We describe a very rare case of tuberculous otitis media (TOM) with direct intracranial extension. The patient was a 55-year-old man who presented to our ENT clinic for evaluation of severe headaches and right-sided otorrhea. A biopsy of granulation tissue obtained from the right external auditory canal demonstrated chronic inflammation that was suggestive of mycobacterial infection. Magnetic resonance imaging of the brain indicated intracranial extension of TOM through a destroyed tegmen mastoideum. After 2 months of antituberculous medication, the headaches and otorrhea were controlled, and the swelling in the external ear canal subsided greatly. Rarely does TOM spread intracranially. In most such cases, intracranial extension of tuberculosis occurs as the result of hematogenous or lymphogenous spread. In rare cases, direct spread through destroyed bone can occur, as it did in our patient.

Quantifying response to intracranial pressure normalization in idiopathic intracranial hypertension via dynamic neuroimaging.

PubMed

Lublinsky, Svetlana; Kesler, Anat; Friedman, Alon; Horev, Anat; Shelef, Ilan

2018-04-01

Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure without a clear cause. To investigate dynamic imaging findings in IIH and their relation to mechanisms underlying intracranial pressure normalization. Prospective. Eighteen IIH patients and 30 healthy controls. T 1 -weighted, venography, fluid attenuation inversion recovery, and apparent diffusion coefficients were acquired on 1.5T scanner. The dural sinus was measured before and after lumbar puncture (LP). The degree of sinus occlusion was evaluated, based on 95% confidence intervals of controls. We studied a number of neuroimaging biomarkers associated with IIH (sinus occlusion; optic nerve; distribution of cerebrospinal fluid into the subarachnoid space, sulci and lateral ventricles (LVs); Meckel's caves; arachnoid granulation; pituitary and choroid plexus), before and after LP, using a set of specially developed quantification techniques. Relationships among various biomarkers were investigated (Pearson correlation coefficient) and linked to long-term disease outcomes (logistic regression). The t-test and the Wilcoxon rank test were used to compare between controls and before and after LP data. As a result of LP, the following were found to be in good accordance with the opening pressure: relative compression of cerebrospinal fluid (R = -0.857, P < 0.001) and brain volumes (R = -0.576, P = 0.012), LV expansion (R = 0.772, P < 0.001) and venous volume (R = 0.696, P = 0.001), enlargement of the pituitary (R = 0.640, P = 0.023), and shrinkage of subarachnoid space (R = -0.887, P < 0.001). The only parameter that had an impact on long-term prognosis was cross-sectional size of supplemental drainage veins after LP (sensitivity of 92%, specificity of 20%, and area under the curve of 0.845, P < 0.001). We present an approach for quantitative characterization of the intracranial venous system and its implementation as a diagnostic assistance

Ideal Internal Carotid Artery Trapping Technique without Bypass in a Patient with Insufficient Collateral Flow.

PubMed

Chung, Joon Ho; Shin, Yong Sam; Lim, Yong Cheol; Park, Minjung

2009-04-01

Internal carotid artery (ICA) trapping can be used for treating intracranial giant aneurysm, blood blister-like aneurysms and ICA rupture during the surgery. We present a novel ICA trapping technique which can be used with insufficient collaterals flow via anterior communicating artery (AcoA) and posterior communicating artery (PcoA). A patient was admitted with severe headache and the cerebral angiography demonstrated a typical blood blister-like aneurysm at the contralateral side of PcoA. For trapping the aneurysm, the first clip was placed at the ICA just proximal to the aneurysm whereas the distal clip was placed obliquely proximal to the origin of the PcoA to preserve blood flow from the PcoA to the distal ICA. The patient was completely recovered with good collaterals filling to the right ICA territories via AcoA and PcoA. This technique may be an effective treatment option for trapping the aneurysm, especially when the PcoA preservation is mandatory.

Very Few Exercise-Induced Arterialized Gas Bubbles Reach the Cerebral Vasculature.

PubMed

Barak, Otto F; Madden, Dennis; Lovering, Andrew T; Lambrechts, Kate; Ljubkovic, Marko; Dujic, Zeljko

2015-09-01

Arterialization of venous gas emboli (VGE) formed after surfacing from SCUBA diving can become arterial gas emboli (AGE) through intrapulmonary arterial-venous anastomoses that open with exercise. We recruited twenty patent foramen ovale-negative SCUBA divers and conducted a field and a laboratory study with the aim of investigating the appearance of AGE in intracranial vessels. At the field, they performed a single dive to a depth of 18-m sea water with a 47-min bottom time and a direct ascent to the surface. Transthoracic echocardiography was used to score VGE and AGE, and transcranial Doppler was used to visualize middle and posterior cerebral arteries with automated objective bubble detection. Observations were conducted for 45-min after dive at rest and at the laboratory after agitated saline injection at rest and throughout an incremental cycle supine exercise test until exhaustion and for 10 min of recovery. After resurfacing, all divers presented endogenous VGE and arterialization was present in three divers. Saline contrast injection led to AGE in nine of 19 subjects at rest. AGE that reached the cerebral arteries after dive were recorded in two divers at 60 W, three at 90 W, five at 120 W, six at 150 W, and four at 180 W and in three, four, five, nine, and nine, respectively, after saline contrast injection in the laboratory. All divers had AGE grades of 1 or 2, and only single AGE reached the cerebral vasculature. These data suggest that few emboli of venous origin reach the brain through exercise-induced intrapulmonary arterial-venous anastomoses but cerebral embolization is not high risk in the studied population.