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ABSTRACT: Superficial siderosis of the central nervous system (CNS) is a rare disorder caused by deposition of hemosiderin in neuronal tissue in the subpial layer of the CNS due to slow subarachnoid or intraventricular hemorrhage. The most common neurologic manifestations include progressive gait ataxia, sensorineural hearing loss, and corticospinal tract signs. We present a case of superficial siderosis in a 43-year-old man who presented to the Emergency Department with sudden onset bilateral visual deterioration and a loss of consciousness. A hemorrhagic giant prolactinoma was diagnosed based on brain CT scan, T1-weighted MRI, and an endocrine blood examination. Susceptibility-weighted non-contrast MRI showed pathognomonic signs of superficial siderosis in the form of a hypointensity rim surrounding the brainstem, cerebellar fissures, and cranial nerves VII and VIII. This report demonstrates that superficial siderosis can be caused by pituitary apoplexy.
Journal of Clinical Neuroscience 05/2013; · 1.25 Impact Factor
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ABSTRACT: We aimed to compare the presentation, management, and clinical course in patients with perimesencephalic and nonperimesencephalic (aneurysmal) bleeding patterns on noncontrast CT, but negative initial 4-vessel digital subtraction angiography (DSA).
We retrospectively reviewed clinical and imaging data for 280 patients presenting with spontaneous SAH admitted between 2005 and 2011. We identified 56 patients (20%) with SAH diagnosed on high resolution head CT performed within 48 hours of admission, and negative initial DSA, and divided them into perimesencephalic and non-perimesencephalic groups based on hemorrhage patterns. Patients with traumatic subarachnoid bleeding and those with initial positive DSA were excluded from this analysis.
Perimesencephalic SAH was seen in 25 patients (45%); non-perimesencephalic bleeding patterns were seen in 31 (55%). All patients with perimesencephalic SAH presented with Hunt and Hess (HH) I, versus 45% HH I and 55% HH II-IV in those with non-perimecenphalic SAH. All patients with perimesencephalic SAH achieved modified Rankin score (mRS) 0 at discharge and 6-month follow-up, compared with 45% mRS 0 at discharge and 68% at 6-month follow-up in non-perimesencephalic SAH. Patients with perimesencephalic SAH presented a uniformly uncomplicated clinical course. Among non-perimesencephalic SAH patients there were 19 neurological/neurosurgical and 10 medical complications, two small aneurysms diagnosed at follow-up DSA, and one death.
In this series, perimesencephalic SAH was associated with good clinical grades, consistently negative initial and follow-up angiograms, and an excellent prognosis. In contrast, non-perimesencephalic SAH was associated with a worse clinical presentation, higher complication rates, higher rates of true aneurysm detection on follow-up angiogram, and a poorer outcome.
Neurological Research 03/2013; 35(2):117-22. · 1.52 Impact Factor
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ABSTRACT: Cerebral sinodural thrombosis (CSDT) is a rare complication of minor head trauma in children. Despite recommendations, anticoagulation is frequently withheld. We aimed to evaluate the etiology, clinical presentation, risk factors, diagnosis, treatment, and outcome of pediatric CSDT following minor head trauma, and specifically to evaluate factors associated with anticoagulation use following minor head trauma in pediatric patients with CSDT. A literature search from 1990 to 2012 identified manuscripts discussing epidemiology, risk factors, clinical presentation, management, and outcome in pediatric patients with CSDT subsequent to minor head trauma. One pediatric patient diagnosed with CSDT following minor head trauma in our institution was also included in the study. There were 18 pediatric patients with CSDT following minor trauma, including the current patient. Mean patient age was 7.8years (range 23months-15years). There was a strong female predominance (2.4:1). Vomiting and headache were the most common symptoms. Five patients had pre-existing risk factors (gastroenteritis, protein S deficiency, estroprogestenic medication, elevated antiphospholipid antibodies, malnutrition). Anticoagulation was administered to six patients with additional risk factors, severe symptoms, or deterioration. There was no mortality, 12 patients recovered fully, and four patients improved with residual symptoms. One patient required lumboperitoneal shunt placement. Pediatric CSDT is a rare complication of minor head trauma, with variable presentation. Anticoagulation has generally been reserved for patients suffering from severe symptoms, for those who deteriorate neurologically during observation, and for those who suffer from a concomitant prothrombotic disorder.
Journal of Clinical Neuroscience 02/2013; · 1.25 Impact Factor
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ABSTRACT: Flow diverters constitute a new generation of flexible self-expanding stent-like devices with a high metal-surface area coverage, specifically designed for the endovascular management of complex cerebral aneurysms. Recently, other potential applications for these devices in the field of occlusive cerebrovascular disease have been described. In vertebral artery dissections causing occlusion associated with a burden of extensive clots, we have found that the reduced porosity of the diverter mesh serves as an effective barrier to in-stent clot protrusion and distal embolization. We describe the novel use of a flow diverter for the management of an occlusive traumatic vertebral artery dissection. Diverter implantation allowed subsequent angioplasty.
Journal of Clinical Neuroscience 02/2013; · 1.25 Impact Factor
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ABSTRACT: Endovascular embolization is accepted as an alternative to surgical management of spinal dural arteriovenous fistulas (DAVF) in most patients; however, when the feeder vessel arises from the trunk vessel with an acutely angled origin, microcatheter navigation may be difficult, hazardous, and sometimes impossible. We propose a technique that eases microguidewire engagement and microcatheterization of arteries that arise at very acute angles with the assistance of a parallel compliant balloon that acts as supporter, guider, and protector. This technique was successfully applied in three consecutive patients with spinal DAVF with unfavorable vascular anatomy that limited selective microcatheterization. The balloon supports and guides the microguidewire along the feeder (supportive role). The balloon can then be placed at the origin of the feeder vessel and inflated during embolization to prevent liquid agent reflux (protective role). Use of this technique as a first option reduces procedure time and radiation exposure. A limiting factor is the need for a relatively large working channel to allow the combined use of a balloon and a microcatheter.
Journal of Clinical Neuroscience 11/2012; · 1.25 Impact Factor
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ABSTRACT: A 4-month-old female presented with a dural arteriovenous fistula (DAVF), which was successfully managed using endovascular techniques. There are very few case series reporting DAVF in infants younger than 12months and, to our knowledge, only 60 pediatric patients with DAVF have been reported to date. Although most DAVF have a benign course, they can result in life-threatening hemorrhage. Endovascular therapies are usually indicated in the management of these neurosurgical vascular malformations. Endovascular therapy of DAVF in neonatal patients presents some major issues. Gaining arterial access may be problematic in femoral arteries too small for the introduction of a sizeable guiding catheter. The volumes of contrast and infused fluids must be carefully monitored to prevent fluid overload. Radiation exposure should be restricted as far as possible. This report contributes to the limited body of evidence on neonatal DAVF and its endovascular management.
Journal of Clinical Neuroscience 09/2012; · 1.25 Impact Factor
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ABSTRACT: Banana boat rides are a popular form of recreation worldwide. Recommendations that speed should not exceed 15 mph, passengers should wear protective gear, and an observer should be present on the towing boat are generally ignored. Medical personnel at tourist venues and general practitioners may not be attuned to the risk of serious injury. We present our experience in the management carotid- and vertebral artery dissections sustained by 44- and 23-year-old males during banana boat rides. In both cases, the dissections were misdiagnosed until patients presented to the Emergency Department two days after injury. In the first patient, medical management failed and endovascular treatment was required due to neurological deterioration. In patient two, anticoagulation therapy prevented embolic sequelae. Boat operators, passengers, and the medical personnel who are first to see these patients should be aware of the risk of arterial dissection to facilitate early detection of these potentially life-threatening injuries.
Journal of Clinical Neuroscience 07/2012; 19(9):1323-5. · 1.25 Impact Factor
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ABSTRACT: OBJECTIVE: Tandem occlusions of the internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous thrombolytic therapy, and are usually managed by endovascular means. This study describes experience with stent-assisted endovascular ICA revascularization and stent-based thrombectomy. METHODS: In patients with tandem ICA-middle cerebral artery (MCA)/distal ICA occlusion, the carotid occlusion was recanalized by primary angioplasty and stent implantation, and the distal occlusion by stent-based thrombectomy. Two variant techniques are described. RESULTS: Seven consecutive patients, mean age 64.1 years (range 49-75) and mean admission National Institutes of Health Stroke Scale score of 23, were included. Occlusion sites were tandem proximal ICA and MCA trunk (six patients) and tandem proximal left ICA and ICA terminus (one patient). Complete recanalization with complete perfusion (Thrombolysis in Myocardial Infarction [TIMI] 3, Thrombolysis in Cerebral Infarction [TICI] 3) was achieved in six patients and partial recanalization with partial perfusion (TIMI 2, TICI 2A) in one. Mean time to therapy was 4.9 h (range 3-6.5); mean time to recanalization was 55 min (range 38-65 min). CT performed 1 day after recanalization showed cortical sparing (>90% of the cortex at risk) in seven patients. Five patients (72%) presented with good clinical outcome (modified Rankin Scale (mRS) score 0-2) at 1 month; one patient (patient No 7) reached an mRS score of 3 and one patient died. CONCLUSIONS: In selected cases of acute ICA occlusion and concomitant major vessel embolic stroke, angioplasty and stenting of the proximal occlusion and stent-based thrombectomy of the intracranial occlusion may be feasible, effective and safe, and provide early neurological improvement. Further experience and prospective studies are warranted.
Journal of neurointerventional surgery 06/2012; · 0.92 Impact Factor
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ABSTRACT: The use of a ventriculoperitoneal (VP) shunt to treat uncontrollable intracranial hypertension in patients with cryptococcal meningitis without hydrocephalus is somewhat unusual and still largely unreported. However, uncontrollable intracranial hypertension without hydrocephalus in these patients is a potentially life-threatening condition. Early diagnosis and shunt placement are essential to improve survival and neurological function. We report uncontrollable intracranial hypertension without hydrocephalus in a 23-year-old woman, which was successfully managed by VP shunt placement.
Journal of Clinical Neuroscience 06/2012; 19(8):1175-6. · 1.25 Impact Factor
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ABSTRACT: Hemorrhage secondary to postoperative pseudoaneurysm is a rare event, but may complicate the clinical course of straightforward and common interventions such as sinonasal procedures, tonsillectomy, and maxillofacial and plastic surgeries. We report our experience with the endovascular management of iatrogenic pseudoaneurysm in eight patients who had undergone recent craniomaxillofacial surgery. Computed tomography (CT), including CT-angiography, detected only three of the eight lesions. In all patients, endovascular embolization achieved successful occlusion of the pseudoaneurysm without local or general procedure-related complications. Immediate proximal arterial occlusion with detachable coils was performed in every case, and pseudoaneurysm coiling was performed in three cases presenting with active hemorrhage. Endovascular therapy proved to be safe and effective in the management of postoperative pseudoaneurysms. Surgeons involved in the craniomaxillofacial procedures should be aware of this complication and its management.
Journal of Clinical Neuroscience 05/2012; 19(5):649-54. · 1.25 Impact Factor
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ABSTRACT: Flow diverters constitute a new generation of flexible self-expanding, stent-like devices with a high-metal surface-area coverage for the endovascular management of wide-necked, fusiform, large, and giant unruptured intracranial aneurysms. They achieve aneurysm occlusion through endoluminal reconstruction of the dysplastic segment of the parent artery that gives rise to the aneurysm. To our knowledge, there is no report on the use of flow diverters for the management of occlusive cerebrovascular disease. We describe the novel use of telescoped flow diverters in a construct that acts as an endovascular bypass for the management of symptomatic chronic carotid occlusion. In long carotid occlusions with a burden of extensive clots and atherosclerotic plaque, we found that the reduced porosity of the diverter mesh serves as an effective barrier to in-stent clot protrusion and distal embolization. Diverter implantation allows subsequent angioplasty. With this patient report, we propose a new potential application for flow diverters in the management of occlusive cerebrovascular disease. The optimal application of these devices will continue to be defined as clinical experience evolves.
Journal of Clinical Neuroscience 05/2012; 19(7):1026-8. · 1.25 Impact Factor
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ABSTRACT: We report a patient with a giant unruptured supraclinoid aneurysm treated by endovascular embolization by means of bare coils and implantation of a flow diverterstent. Eight weeks after the embolization, she presented with uncinate seizures. Neuroradiological examination revealed de novo postembolization perianeurysmal edema, which has been described only rarely. A brief course of oral steroids successfully controlled the seizures. Perianeurysmal edema must be considered a potential complication after embolization of large aneurysms with coils and other means, and needs to be considered as a differential diagnosis in patients with unusual neurological symptoms at either the acute or delayed stages. To our knowledge, this is the first report of postembolization perianeurysmal edema occurring after successful occlusion by means of bare coils and a flow diverterstent. This report contributes to the growing evidence on adverse post-coiling inflammatory reactions, and specifically on perianeurysmal edema.
Journal of Clinical Neuroscience 03/2012; 19(3):474-6. · 1.25 Impact Factor
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ABSTRACT: The poor natural history of central retinal artery occlusion (CRAO) is usually not modified with conventional, conservative management techniques. Guidelines for selective intraarterial ophthalmic thrombolysis are still lacking. While many centers continue to perform this procedure with promising results, others are reluctant due to conflicting findings in recent studies. We present our experience in a 36-year-old male with CRAO. Based on the patient's clinical presentation, we planned to perform selective intraarterial ophthalmic thrombolysis via the ophthalmic artery. When angiography demonstrated that the retina was not supplied by the ophthalmic artery, but by a meningo-ophthalmic artery branching from the internal maxillary artery, we instead administered thrombolytic agents via the meningo-ophthalmic artery. The patient's vision recovered completely, with visual acuity and visual field examination at 30 day follow up comparable to his pre-treatment status. This case emphasizes the need for external carotid artery examination in cases of nonvisualization of the ophthalmic artery. In addition, it illustrates the successful use of the meningo-ophthalmic artery to perform selective intraarterial thrombolysis for CRAO.
Journal of Clinical Neuroscience 03/2012; 19(3):462-4. · 1.25 Impact Factor
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ABSTRACT: The complex anatomic features of wide-necked anterior communicating artery aneurysms represent an endovascular challenge. Compliant balloons and microstents are frequently required to achieve aneurysm occlusion. When the angle between the A1 and A2 segments is acute, microcatheter navigation is hazardous, and may be difficult or sometimes impossible with standard techniques. We present our technique using a support balloon to facilitate guidewire engagement and navigation of A2, and to assist with microcatheterization in this unfavorable vascular anatomy.
Journal of Clinical Neuroscience 03/2012; 19(3):452-4. · 1.25 Impact Factor
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ABSTRACT: Epistaxis generally responds to conservative management, but a more invasive approach, such as superselective embolization, is sometimes justified. We report our experience with endovascular procedures in 19 patients from 2002 to 2011 for the treatment of refractory idiopatic posterior epistaxis. The sphenopalatine artery and distal internal maxillary arteries were embolized in all patients. Unilateral embolization was performed in 12 patients (63%), bilateral embolization in seven (37%). Additional embolization of the descending palatine artery was performed in eight patients (42%) and embolization of the facial artery and palatine arteries in four (21%). In one patient the distal ophthalmic artery was embolized with n-butyl cyanoacrylate. No minor or major complications occurred in relation to the embolization procedures. The average hospital stay was 11.1±8.6 days, including an average 5.2±3.4 days after embolization. Average follow-up after discharge was 21.3±25.7 months. Superselective endovascular embolization proved safe and effective in controlling idiopathic epistaxis, refractory to other maneuvers.
Journal of Clinical Neuroscience 02/2012; 19(5):687-90. · 1.25 Impact Factor
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ABSTRACT: Traumatic internal carotid artery dissection (CAD) has a potentially grave outcome. Anticoagulant therapy may be ineffective or contraindicated; surgery impractical. We present our experience with endovascular stenting in CAD patients.
From 2004 to 2011, 23 patients with angiographically proven traumatic CAD underwent endovascular stent-assisted arterial reconstruction based on clinical and radiographic criteria: contraindication or failure of anticoagulation, evidence of impending ischemic stroke, or need for urgent intracranial revascularization. Dissections were graded based on degree of stenosis and extent of injury.
Seventeen patients (73.9%) presented with stroke or transient ischemic attack. Carotid revascularization was achieved with one (11 patients, 48%) or multiple stents (12 patients, 52%); distal protection was used rarely (three patients, 13%). No complications were directly attributed to stenting. Mean dissection-related stenosis improved from 72% ± 28.87% to 4% ± 8.29%. At a mean clinical follow-up of 28.7 months ± 31.9 months, 16 patients (69.6%) improved, six (26.1%) remained stable, and one (4.3%) had died secondary to multiple traumatic injuries. At long-term follow-up, no patient had a transient ischemic attack or stroke or presented evidence of de novo in-stent stenosis or stent thrombosis. There were no neurologic sequelae after partial or total discontinuation of antiplatelet therapy in seven patients undergoing trauma-related surgeries.
Selected cases of traumatic CAD can be safely managed by endovascular stent-assisted angioplasty. Procedural complications are infrequent; the need for postprocedure antiplatelet therapy is a concern. Early detection is essential to avoid stroke. Stenting restores the integrity of the vessel lumen immediately, efficiently prevents the occurrence or recurrence of ischemic events, and avoids the need of long-term anticoagulation.
The journal of trauma and acute care surgery. 01/2012; 72(1):216-21.
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ABSTRACT: Stent-based mechanical thrombectomy was recently proposed as an effective alternative to other mechanical techniques to achieve recanalization of large-vessel embolic occlusions in the anterior circulation. To our knowledge, there are no reports of the use of this technique in acute basilar artery occlusion (ABAO). We present a patient with complete endovascular recanalization of ABAO using a stent-based thrombectomy technique. Advantages and limitations of this technique in the management of ABAO are discussed. The stent-thrombectomy technique is promising, and will need further evaluation in posterior circulation stroke.
Journal of Clinical Neuroscience 12/2011; 18(12):1718-20. · 1.25 Impact Factor
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ABSTRACT: We report the use of a self-expanding stent as a thrombectomy device in 17 patients (mean age 64.3 years) with major ischemic stroke secondary to large vessel occlusion. The patients had a mean National Institutes of Health Stroke Scale (NIHSS) score of >12, no cerebral hemorrhage or early infarction signs that affected more than 1/3 of the endangered territory, and an insufficient collateral supply. Within 8 hours of symptom onset, a stent (Solitaire; ev3, Irvine, CA, USA) was deployed across the occluded segment (endovascular bypass step). A repeat angiogram was performed to evaluate reconstituted flow. The guide-catheter balloon was inflated for proximal carotid occlusion. The partially deployed stent was slowly pulled back (mechanical thrombectomy step) under continuous aspiration. Complete recanalization (TIMI grade 3 flow) was achieved in fewer than 66 minutes after femoral access in all patients, with complete clot removal in a mean of two thrombectomy attempts. No stent was permanently implanted. Two patients developed asymptomatic hemorrhagic transformation (11.8%). Two patients presented post-recanalization parenchymal hemorrhage (11.8%); one suffered an intracerebral and intraventricular hemorrhage 12 hours after a successful and uneventful procedure and died 10 days later. The modified Rankin Scale scores were 0 to 2 in 15 patients (88.2%) and 3 in one patient (5.9%) at 1 month. In our preliminary experience, rapid stent-based mechanical thrombectomy has had unprecedented success.
Journal of Clinical Neuroscience 11/2011; 19(1):39-43. · 1.25 Impact Factor
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ABSTRACT: Giant dolichoectatic and fusiform aneurysms of the vertebrobasilar artery are among the most difficult and dangerous aneurysms to treat. Conservative management may be reasonable in asymptomatic elderly patients. Nevertheless, due to the frequent presence of mass effect on the brainstem and the risks of thromboembolic events and rupture, these aneurysms often demand treatment rather than observation. With the advancement of endovascular techniques some of these lesions have become treatable without the high morbidity and mortality rates associated with open surgical treatment. When dealing with giant, progressively enlarging symptomatic aneurysms, more limited therapeutic alternatives are available. The authors present a case of a growing megadolichoectatic vertebrobasilar artery aneurysm causing major disability due to increasing mass effect in a 51-year-old man. The aneurysm was treated with flow diversion by placing multiple telescoped stents and diverters ("diverter-in-stent" technique), achieving thrombosis of the aneurysm and reduction of the mass effect on the brainstem, with neurological improvement. The successful clinical and angiographic results observed in our case of giant dolichoectasic vertebrobasilar aneurysm contribute to the literature on giant aneurysms treated by means of flow diversion.
Journal of Clinical Neuroscience 11/2011; 19(1):166-70. · 1.25 Impact Factor
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The Israel Medical Association journal: IMAJ 11/2011; 13(11):705-6. · 1.02 Impact Factor
