Angiographic Presentation Research Articles

Organized Thrombus Masquerading as Spontaneous Coronary Artery Dissection: A Set of Two Cases

Background Spontaneous coronary artery dissection (SCAD) often impacts young women who lack traditional risk factors. Diagnosing SCAD can be challenging due to its diverse angiographic presentations and resemblance to other conditions, such as organized thrombus. Case Summary We present two cases involving middle-aged male smokers, each experiencing chest pain lasting over 12 hours. Both patients exhibited ST-segment elevation in the anterior leads on ECG, anterior wall hypokinesia, and an LVEF of 40% on 2D echocardiography. Immediate coronary angiography revealed dye staining and multiple radiolucent lumens in the LAD, indicative of SCAD. Optical coherence tomography (OCT) identified an organized thrombus with a distinctive “Swiss cheese” pattern, differing from the usual radiolucent false lumen associated with SCAD. Both patients were successfully treated with PCI, including thrombus aspiration and stent placement. Take-home message Relying solely on angiography for SCAD diagnosis may overlook organized thrombus. Redefining SCAD criteria and utilizing multimodal imaging like OCT in all cases is essential.

Endovascular Detection of Catheter-Thrombus Contact by Vacuum Excitation.

The objective of this work is to introduce and demonstrate the effectiveness of a novel sensing modality for contact detection between an off-the-shelf aspiration catheter and a thrombus. A custom robotic actuator with a pressure sensor was used to generate an oscillatory vacuum excitation and sense the pressure inside the extracorporeal portion of the catheter. Vacuum pressure profiles and robotic motion data were used to train a support vector machine (SVM) classification model to detect contact between the aspiration catheter tip and a mock thrombus. Validation consisted of benchtop accuracy verification, as well as user study comparison to the current standard of angiographic presentation. Benchtop accuracy of the sensing modality was shown to be 99.67%. The user study demonstrated statistically significant improvement in identifying catheter-thrombus contact compared to the current standard. The odds ratio of successful detection of clot contact was 2.86 (p = 0.03) when using the proposed sensory method compared to without it. The results of this work indicate that the proposed sensing modality can offer intraoperative feedback to interventionalists that can improve their ability to detect contact between the distal tip of a catheter and a thrombus. By offering a relatively low-cost technology that affords off-the-shelf aspiration catheters as clot-detecting sensors, interventionalists can improve the first-pass effect of the mechanical thrombectomy procedure while reducing procedural times and mental burden.

Abstract TP215: Endovascular and Medical Management Strategies for Caroticocavernous Fistulae: A Single Center Retrospective Safety and Efficacy Analysis

Background: Caroticocavernous fistulae (CCF) are a rare subtype of intracranial arteriovenous fistulae with variable clinical and angiographic presentations. This study aimed to describe the clinical outcomes in a cohort of CCF patients and identify clinical and angiographic features differentiating patients more likely to benefit from endovascular intervention. Methods: A single-center, retrospective analysis was performed to identify all patients with angiographically-confirmed CCF between 2000 and 2022. Pertinent data, including clinical symptoms, angiographic findings, treatment strategies, recurrence rates, and complications, was collected. Results: A total of 84 patients were included, of whom 67 (80%) underwent endovascular intervention and 17 (20%) were conservatively managed. Primary endovascular techniques were transvenous coil embolization (78%), feeder artery embolization (16%), and ICA flow diversion (8%). High-risk clinical symptoms, such as reduced visual acuity, and angiographic features, such as cortical and ophthalmic venous reflux, were more common in the intervention group (p<0.05). All direct (Barrow Type A) CCFs underwent endovascular intervention (32% vs 0%, p=0.005), while indirect (Barrow types B-D) CCFs were common in the conservatively managed group (100% vs 68%, p=0.005). 31% of treated CCFs required retreatment, which primarily occurred with Barrow type D CCFs and following transvenous coil embolization. Procedure-related complications occurred in 10% of cases and consisted of cranial nerve palsies (n=5), asymptomatic intracranial dissection (n=1), and asymptomatic distal thromboembolic occlusion (n=1). Conclusion: High-risk symptoms and angiographic features favor endovascular intervention. Various embolization techniques, including transvenous coil embolization, proved safe and effective. In select CCF patients without high-risk clinical or angiographic features, conservative observation is a safe and effective alternative to endovascular embolization. Complications were rare, and most were transient, emphasizing the safety of endovascular management. Longitudinal angiographic surveillance is essential for monitoring fistula persistence or recurrence.

Assessment of Risk Factors and Angiographic Profile in Left Main Coronary Artery Disease

Background: Diagnostic and management challenges with unpredictable angiographic presentations are encountered in left main coronary artery disease (LMCAD) patients. Therefore, this study was designed to evaluate the prevalence, risk factors, angiographic profile, and outcomes associated with LMCAD at 6-month follow-up. Materials and Methods: This was a prospective observational study where a total of 1474 patients undergoing coronary angiography were enrolled between March 2018 and August 2019. Demographic details, physical examination, and routine biochemical investigations were reported. Obstructive LMCAD patients were managed either with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) according to syntax score, and outcomes were recorded at 6-month follow-up. Results: The mean age of the overall study population (1474 patients) was 59 ± 8.1 years with male 959 (65%) preponderance. Obstructive LMCAD was observed in 103 (6%) patients. Smoking was the prime risk factor associated with obstructive LMCAD observed among 58 (56%) patients followed by hypertension in 45 (43%), dyslipidemia in 42 (40%), obesity in 26 (25%), and diabetes mellitus in 23 (22%) patients. Among 41 (40%) obstructive LMCAD patients, non-ST-elevation myocardial infarction/unstable angina was the major presentation. The majorly affected target vessels were left anterior descending artery (100%) and left circumflex artery (80%) among 103 and 83 patients, respectively. Triple-vessel disease was predominantly observed among 63 (62%) obstructive LMCAD patients. PCI and CABG were performed in 19 (18.4%) and 27 (26.2%) patients with a mean syntax score of 20 and 31, respectively. Conclusion: Smoking, advanced age, diabetes, and dyslipidemia were significantly associated risk factors of LMCAD.

Dissecção espontânea da artéria coronária, uma doença multifatorial: perspectivas da experiência de um centro

Background: Although it is a poorly known disease, spontaneous coronary artery dissection is an important and frequently underdiagnosed cause of non-atherosclerotic acute coronary syndrome, particularly in women. The objective of this study was to characterize a consecutive sample of patients diagnosed with spontaneous coronary artery dissection with respect to predisposing and precipitating factors; clinical and angiographic presentation; management; occurrence of adverse cardiac events; recurrence; and de novo spontaneous coronary artery dissection. Methods: Longitudinal, observational, retrospective, single-centre study, including patients diagnosed with spontaneous coronary artery dissection (n=60) admitted between January 2010 and December 2020. Results: Median age was 55 years, and 83% were women. Most patients (60%) presented without any or just one cardiovascular risk factor. Non-ST-segment elevation acute myocardial infarction accounted for 67% of clinical presentations. The most frequently affected coronary artery was the left anterior descending (47%). Most lesions (77%) appeared on angiography as type 2 spontaneous coronary artery dissection. Conservative management was chosen as the initial approach in most patients (72%). The overall incidence of de novo spontaneous coronary artery dissection was not significantly different among patients initially managed with revascularization as compared to conservative treatment (p=0.953). However, spontaneous coronary artery dissection recurrence occurred in the originally involved vessel in 3 of 15 patients initially managed with revascularization, as compared to only one among 43 patients treated conservatively (p<0.05). Conclusion: Spontaneous coronary artery dissection occurs more often in young women. Non- ST-segment elevation acute myocardial infarction was the most frequent clinical presentation involving mainly the left anterior descending artery. Revascularization did not protect from recurrence.

Acute Left Circumflex Coronary Artery Occlusion - Diagnostic Problems of Initial Electrocardiographic Changes.

Background: Acute coronary syndrome (ACS) with occlusion of the left circumflex coronary artery (LCX) poses diagnostic problems that may lead to a delay in reperfusion.Methods and Results: From a group of 1,269 consecutive patients with ACS, 138 patients with ACS due to LCX occlusion were analyzed for clinical, electrocardiographic, and angiographic presentations, as well as door-to-balloon (DTB) time. Electrocardiographic changes were classified into 4 patterns: ST-segment elevation in inferior/lateral leads (ST-E); ST-segment depression in V1–V4 (ST-D); no significant ST changes (No-ST); and others. The No-ST group was associated with a longer DTB time (P<0.0001) compared with the ST-E and ST-D groups. Compared with the No-ST and ST-E groups, the ST-D group presented with a more advanced Killip class (P=0.003), greater peak creatine phosphokinase (P=0.007) and peak creatine kinase-MB (P=0.006), more frequent proximal LCX occlusion (P=0.007), and worse 1-year outcomes (P=0.0034).Conclusions: One-third of ACS patients with LCX occlusion showed no ST-segment changes, resulting in significantly longer DTB time. Improving diagnostic accuracy is challenging but critical to avoid delayed reperfusion in these patients without electrocardiographic changes.

Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas

BackgroundAnterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous...

Characteristics and Prognosis of Patients With Fibromuscular Dysplasia in a Population of Spontaneous Coronary Artery Dissections (from the French Registry of Spontaneous Coronary Artery Dissections “DISCO”)

Spontaneous coronary artery dissection (SCAD) and fibromuscular dysplasia (FMD) are pathologies that appear to be closely related. This study compares the characteristics of the FMD population to the non-FMD population in a SCAD cohort. It thus assesses the involvement of the FMD phenotype in a SCAD population. From the data of the French DISCO registry, we included patients with a diagnosis of SCAD and in whom a search for FMD was performed. We collected the following characteristics of this population: the clinical and angiographic presentation, the data concerning the management, and the events occurring during the follow-up. In the 373 SCADs confirmed in the DISCO registry, we obtained imaging data for 340 of them. FMD was found in 45% of cases. The mean age was higher in the FMD group, 53.2 ± 8.8 years, versus 50.1 ± 11 years in the non-FMD group. High blood pressure and postmenopausal status were significantly higher in the FMD group. Clinical presentation, angiographic data, and management were comparable. The major adverse cardiac event rate and recurrence rate were not different between the 2 groups after 1 year of follow-up. In conclusion, we confirmed a 45% prevalence of FMD in the SCAD population. The median age was higher in the FMD group, suggesting that FMD may develop over time. The rate of major adverse cardiac events and recurrence were similar in the FMD group versus the non-FMD group after 1 year of follow-up.

Acute Occlusion of the Infarct-Related Artery as a Predictor of Very Long-Term Mortality in Patients with Acute Myocardial Infarction.

Aim The survey's aim was to examine the significance of infarct-related artery (IRA) occlusion (verified angiographically) on very long-term outcomes of patients with acute myocardial infarction, within the STEMI and NSTEMI diagnosis. Methods A single-center, nonrandomized, registry-based study on patients treated for acute coronary syndrome with percutaneous coronary intervention between June 2011 and December 2016 was conducted. Patients with angiographically proven IRA occlusion (100% stenosis with TIMI flow 0 distal to occlusion) were categorized as occlusive myocardial infarction (OMI) and patients with patent IRA (50–99% stenosis with TIMI 1–3 flow) were categorized as nonocclusive myocardial infarction (NOMI) and very long-term outcomes were analyzed. Data were collected prospectively from the hospital's PCI registry and the database of the Croatian Institute of Public Health. Results A total of 2450 patients were included in the study. 796 (32.5%) patients had NOMI and 1654 patients (67.5%) had OMI. According to ECG changes, 1534 patients presented with STEMI (62,6%) and 916 with NSTEMI (37,8%). 88% of STEMI patients presented with OMI and 12% with NOMI, while patients with NSTEMI in 33,8% presented with OMI and in 66,81% with NOMI. A median follow-up was 4.7 years. There was no significant difference in cardiovascular mortality between the groups (14.8% vs 13.1%; OMI vs NOMI, respectively; p=0.374) neither in all-cause mortality (19% vs 21.5%; OMI vs NOMI, respectively; p=0.374). Patients with NSTEMI had a significantly higher very long-term mortality (21.6% vs 18.1%; NSTEMI vs STEMI, respectively; p=0.029). Conclusion The main findings of the study are as follows: (1) total IRA occlusion was not associated with higher long-term mortality; (2) NSTEMI was associated with a higher mortality rate compared with STEMI, independent of angiographic presentation (OMI/NOMI); (3) IRA occlusion was not associated with significantly higher mortality rates in patients with STEMI and NSTEMI, respectively.

Acute circumflex coronary artery occlusion; dilemma in diagnosis and management

Abstract Background Acute coronary syndrome (ACS) with occlusion of the circumflex coronary artery (LCX) poses diagnostic dilemma that may lead to a delay in reperfusion. Purpose We sought to assess the diagnostic significance of initial electrocardiography (ECG) changes in patients with acute LCX occlusion in relation to its clinical characteristics and the management. Methods From consecutive 1269 patients with ACS who were admitted to our institution during a 5-year period (2015–2019), 138 patients with ACS due to LCX occlusion were analyzed for clinical, ECG and angiographic presentation, and the door-to-balloon (DTB) time. ECG changes were classified into 4 different patterns: 1) ST-elevation in inferior/lateral leads (ST-E); 2) ST-depression in V1-V4 (ST-D); 3) no significant ST changes (No-ST); and 4) others. Results (1) No-ST pattern was found in 47 patients (34%), ST-E in 47 patients (34%), ST-D in 25 patients (18%) and others in 19 patients (14%). (2) Occlusion site: Proximal LCX; 16 patients with No-ST (34%), 6 patients with ST-E (13%), 13 patients with ST-D (52%). Distal LCX; 28 patients with No-ST (60%), 35 patients with ST-E (74%), 11 patients with ST-D (44%) (p=0.007). (Table) (3) Echocardiographic identification of left ventricular asynergy; 31 patients with No-ST (66%), 38 patients with ST-E (81%), 22 patients with ST-D (88%). (4) No-ST group was associated with longer DTB time; 245 min (170–562 min), compared to 93 min (83–121 min) in ST-E group and 97 min (70–129 min) in ST-D group (p&amp;lt;0.0001). DTB time ≤90 min was significantly uncommon in No-ST group (11%), compared to ST-E group (46%) and ST-D group (43%) (p=0.0004). (Figure) Conclusion One-third of the patients with LCX-ACS showed no ST changes, resulting in significantly longer DTB time. Improving diagnostic accuracy with anticipation for LCX-ACS and the use of echocardiographic examination and also the possible application of posterior leads (V7-V9) recording is challenging but critical to avoid delayed reperfusion and to improve outcomes in these patients without ECG changes. Funding Acknowledgement Type of funding sources: None.

Cross Sectional Data on Profile of Coronary Artery Disease in Human Immunodeficiency Virus Infection Patients in a Tertiary Care Hospital of Central India

Background: Human immunodeficiency virus infection leads to a variety of Cardiovascular manifestations. Pericardial effusion, systemic hypertension, dilated cardiomyopathy, coronary artery disease, pulmonary hypertension, primary as well as secondary cardiac tumours etc are seen in about 30% of patients and the incidence has increased with improved longevity. Coronary artery disease ranging from subclinical atherosclerosis to coronary plaque rupture causing acute coronary syndrome have been documented. The main underlying pathophysiological process is a state of perennial inflammation which leads to initiation and acceleration of coronary atherosclerosis. Objective: To study the coronary angiographic profile in HIV patients. Methodology: HIV patients undergoing coronary angiography were assessed clinically, biochemically and finally by coronary angiography to see the coronary pathoanatomy. Results: Of the 37 HIV patients studied between Jan to Dec 2019, the mean age was 47 years.(19-66 years). Two thirds were males; most common traditional risk factor was dyslipidemia followed by hypertension. Most patients were already on ART and the CD 4 counts ranged from 67-366cells/cumm. Anterior wall MI and unstable angina were the most common clinical presentations. Coronary angiography revealed diffuse disease (both insignificant and significant) of the left anterior descending artery as the most common pattern of angiographic involvement. Conclusion: Coronary artery disease both subclinical and syndromic occurs with increased frequency in HIV patients. The dominant angiographic presentation correlates with the clinical presentation and in our study, left anterior descending artery was more frequently diseased as compared to other coronaries. The most common coronary angiographic pattern was the presence of ectasia and diffuse disease. Keywords: Human immunodeficiency virus, cardiovascular manifestations, coronary artery disease, coronary angiography.

The angiographic presentation of European Moyamoya angiopathy

Background and purposeLittle is known about the angiographic presentation of Moyamoya angiopathy (MMA) in non-Asian patients.MethodsConventional cerebral angiograms from 155 Caucasian patients diagnosed as MMA were analyzed with respect to extracranial champagne bottle neck sign, Suzuki stages, collateral status, as well as presence of aneurysms and posterior cerebral artery stenosis.ResultsIn 84 of 155 angiograms, the extracranial carotid artery was visualized, in 65 of them (77.4%), a champagne bottle neck sign was noted. Of the 278 analyzable hemispheres, 13.7%,11.2%, 37.8%, 27.3%, 8.6%, and 1.4% were classified as Suzuki stage I, stage II, stage III, stage IV, stage V, and stage VI, respectively. Among 280 hemispheres, in 53 hemispheres (18.9%) isolated basal collaterals (pathway I) and in 104 hemispheres (37.1%) choroidal and pericallosal collaterals (including basal collaterals, pathway II) were found. In 74 hemispheres (26.4%) ethmoidal collaterals (pathways III), and in 17 hemispheres (6.1%) vault collaterals were visualized. Patients with higher Suzuki stages IV–VI (p = 0.008) and ethmoidal collaterals (p < 0.001) suffered more often from cerebral hemorrhage. Transient ischemic attacks occurred more frequently in patients with Suzuki stage I to III (p < 0.001). In 10 of 155 patients (6.5%), the angiogram revealed a cerebral aneurysm. In 13 patients (8.4%), a stenotic P1 segment of the posterior cerebral artery was found.ConclusionsThis is so far the largest observational study about angiography in Caucasian European MMA patients. A comparison with Asian data indicates similarity of disease in Caucasian and Asian patients.

Myocardial infarction at a young age: risk factors, clinical presentation, features of management in the hospital

Aim: to study the risk factors, clinical peculiarities, diagnosis and treatment of young patients with myocardial infarction (≤ 44 years).Material and methods. The research included 189 patients, who had MI in the period from January 1, 2015 to December 31, 2019 at the age of ≤ 44; 92.1% of patients were men. The average age of all patients was 41,2 (37.3; 43.6).Results. Most frequent risk factors for the development of MI were: smoking — in 77.8%, essential hypertension — in 73.5%, burdened inheritance — in 49.2%, obesity — in 39.7% and pancreatic diabetes — in 10.6% of all cases. ST segment elevation was registered on the electrocardiogram in 87,8% of patients; 4.2% of them had only thrombolytic therapy; thrombolytic therapy was followed by coronarography with the intention of performing percutaneous coronary intervention (PCI) in 30.7% of cases; coronarography with the intention of performing primary PCI was applied to 54.2% of patients. PCI was performed in 76.5% of patients. 12.2% of patients had acute coronary syndrome without ST-segment elevation, and 95.7% of them had coronarography with the intention of performing percutaneous coronary intervention. PCI was performed in 73.9% of patients. Assignment frequency of beta-adrenergic blocking agent prescription was 95,2% (178 out of 187), аngiotensin-convertingenzyme inhibitors and sartans — 95.2% (178 out of 187), statins — 99.5% (188 of 189), dual antiplatelet therapy — 99.5% (188 out of 189), mineral corticoid receptor antagonists with ejection fraction of left ventricle of heart ≤ 40% — 28.6% (2 of 7).Conclusion. The conducted research aims at the discussion of the vital topic of young patients with myocardial infarction management. It focuses on risk factors, clinical and angiographic presentation, and secondary prevention.

Efficacy and safety of a magnesium stearate paclitaxel coated balloon catheter in the porcine coronary model

BackgroundLocal administration of growth-inhibiting substances such as paclitaxel or sirolimus could reduce the risk of restenosis. In the drug coated balloon (DCB) technology the coating and the applied dose seem to play a major role. The aim of the present preclinical studies was to investigate the efficacy and safety of a specific DCB with paclitaxel as active ingredient and magnesium stearate as excipient. MethodsEvaluation of the coating, drug release and transfer was done ex vivo and in vivo on peripheral arteries. A porcine coronary stent model was chosen to provoke intimal thickening. Conventional uncoated balloons were compared with paclitaxel urea and paclitaxel magnesium stearate coated balloons. QCA and histomorphometry was performed on treated vessels. Three areas of the heart were histologically examined for pathological changes. ResultsQCA and histomorphometry revealed no differences in baseline data between treatment groups. All DCB groups showed a significant reduction of angiographic and histologic parameters describing neointimal formation 4 weeks after treatment (e.g. mean angiographic late lumen loss all coated 0.31 ± 0.18 mm versus 0.91 ± 0.37 mm in the uncoated balloon group). There were no device-related animal deaths or clinical abnormalities. In spite of very slight-to-slight microscopic findings limited to small arterial vessels in downstream tissue there was no change in left ventricular ejection fraction or angiographic presentation of small side branches of treated arteries. ConclusionPaclitaxel DCB using stearate as excipient show a high efficacy in reducing neointima formation after experimental coronary intervention. No evidence of myocardial damage resulting from distal embolization was found.

A Study on Correlation of ECG Findings with Angiographic Presentation among Acute Myocardial Infarction Patients in a Tertiary Care Hospital

A Study on Correlation of ECG Findings with Angiographic Presentation among Acute Myocardial Infarction Patients in a Tertiary Care Hospital

Angiographic SYNTAX score reduction in de novo left main coronary stenosis patients over the last decade: implications for revascularization approach

Abstract Introduction Percutaneous management of left main (LM) coronary artery stenosis is an acceptable alternative to surgery in selected group of patients. Purpose To investigate potential angiographic trends in de novo LM coronary artery stenosis patients. Those may impact revascularization mode but remain undetermined. Methods Clinical records and all consecutive coronary angiograms in our Institution from 1st January 2010 to 31stDecember 2019 were evaluated to identify those with newly diagnosed angiography-significant (≥50% lumen diameter reduction) LM stenosis. Angiographic SYNTAX score (SS) assessment was performed by agreement of two experienced analysts (an angiographic core lab analyst and a Heart Team interventional cardiologist) on anonymized angiograms. Values of the overall SS, SS of the LM lesion and SS beyond LM were determined according to SS assessment methodology. Pearson's correlation and Fisher transformation were used to evaluate parametric variables. Spearman's rho was used to determine trends. Results Overall, out of 12315 coronary angiographies performed in de novo referrals in the last decade, 357 (2.90%) showed significant left main stenosis; the proportion varied from 2.30% to 3.48% annually. Patient mean age was 68.8 years (23.3% women). No temporal trends in patient age or gender occurred over the last decade while the overall SS deceased from a mean value of 35 to 28 (SC=−0.16, p=0.003). Further analysis showed a particular negative trend in the non-LM-SS (SC=−0.17, p=0.001) but not in the LM-SS (SC=0.04, p=0.47). No temporal trend was present is the prevalence of isolated LM stenosis (p=0.48) and no temporal trend in the LM stenosis angiographic severity (&amp;lt;70% vs. ≥70%; p=0.61), LM stenosis location (ostial/mid/bifurcation/entire left main; p=0.30) nor in the number of LM segments affected (SC=0.05, p=0.30). Reduction in the non-LM-SS was associated with a decrease in the number of coronary arteries with a significant angiographic atherosclerotic involvement (SC=−0.12, p=0.03) and in the number of coexisting total occlusions (SC=−0.25, p&amp;lt;0.001). Conclusion(s) (1) In patients with newly diagnosed LM critical stenosis overall angiographic SS showed a statistically significant negative trend over last decade, with a reduction from mean 35 (2010) to 28 points (2019); a finding that may be related to a change in the angiographic presentation of the disease or an earlier identification of LM stenosis patients over time. (2) The overall SS reduction was driven by a decrease in non-LM-SS. This, taken together with the overall SS reduction from above 32 to below 32, favours (as per current guidelines) the endovascular approach to left main revascularization. Our findings suggest an increase in the proportion of LM stenosis patients with angiography feasible to percutaneous intervention. SYNTAX score trends over the last decade Funding Acknowledgement Type of funding source: None

Characteristic imaging features of neurovascular involvement in primary Sneddon's syndrome: an analysis of 12 cases.

Sneddon's syndrome is a cerebrocutaneous non-inflammatory progressive distal arteriopathy, characterized by livedo racemosa, stroke, and neuropsychiatric symptoms. Our aim was to highlight the characteristic neuroimaging features of Sneddon's syndrome that might be helpful to clinicians in timely diagnosis of this entity. Twelve patients (median age 49years, 11 female) with primary Sneddon's syndrome, diagnosed in last 10years, were analyzed from the perspective of magnetic resonance imaging (MRI) features. In addition, a novel pseudoangiomatosis score was defined for grading angiographic abnormalities (range: 0 to 6). Median interval from the onset of neurological symptoms to diagnosis was 6years. Presentation was with acute stroke in 5, seizures in 3, dementia/speech problems in 2, seizures plus cognitive dysfunction in 1, and chronic progressive hemiparesis in 1. All patients had a typical lesion pattern on MRI. This included multiple (median 3) cortical-subcortical supratentorial and cerebellar non-territorial infarcts, accompanied by multifocal cerebral atrophy. Of note, large territorial infarcts due to cerebral parent artery occlusion, an embolic pattern with multi-territorial involvement on diffusion-weighted imaging, small vessel disease features like severe white matter involvement or lacunar infarcts, and cerebral hemorrhage in the absence of anticoagulation were not observed. MRI lesion severity was not correlated with angiographic arteriopathy severity, clinical stage, or presentation symptoms. Sneddon's syndrome is characterized by highly typical clinico-radiological features. Brain MRI has diagnostic value. By knowing the characteristics of the syndrome, misdiagnosis and potentially harmful treatment can be prevented in this entity that might pose a diagnostic challenge.

Efficiency of Endovascular Therapy for Bilateral Cavernous Sinus Dural Arteriovenous Fistula

The principles of endovascular treatment of bilateral cavernous sinus dural arteriovenous fistula (CS-dAVF) are not well established because of the complexity in the number of fistula tracts and their behavior, which seems to be more aggressive. We aimed to determine an efficient technique for endovascular treatment of bilateral CS-dAVF and the associated factors to achieve good clinical and angiographic outcomes. The data were analyzed from 165 consecutive patients diagnosed with CS-dAVF from January 2005 to September 2018. The demographic data included approaching route, embolization times, embolization material, sequence of embolization, number of embolization sessions, and angiographic and clinical outcomes. Interrater agreement of bilateral CS-dAVF diagnosis was performed using the κ coefficient. The factors associated with treatment outcome were analyzed using a Pearson χ2 test. Bilateral CS-dAVF was detected in 43 patients (26%). Angiographic presentations that showed evidence of sinus thrombosis, dangerous venous drainage, and higher Satomi classification were more commonly found in bilateral CS-dAVF than in unilateral CS-dAVF. Good clinical outcome and cure from angiography were obtained in 90% and 74%, respectively. Ipsilateral inferior petrosal sinus-intercavernous sinus-contralateral cavernous sinus catheterization was the major approach route of treatment. The factors associated with improved clinical outcome were transvenous approach, shunt closure, coil embolization, and sequencing the embolization (P < 0.001). Dangerous venous drainage tends to increase in bilateral CS-dAVF. Retrograde ipsilateral inferior petrosal sinus catheterization using coil embolization and sequencing the embolization are the major concerns for treatment.

Spontaneous coronary artery dissection in young female acute coronary syndrome patients: a single-centre retrospective cohort study

Background Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome (ACS), rapidly gaining recognition over the last decade. SCAD occurs predominantly in young, otherwise healthy women and coronary angiogram often lacks typical (atherosclerotic) features. Therefore, SCAD remains notably underdiagnosed. As optimal treatment strategy differs greatly from atherosclerotic ACS, early (differential) diagnosis is crucial. Purpose/Methods In this paper, all coronary angiograms performed for ACS in women up to 50 years of age were retrospectively reviewed by three independent interventional cardiologists. Results The obtained insights are comparable to recent literature. SCAD incidence was 26% in this cohort. Left anterior descending coronary artery was the main affected vessel with SCAD subtype 2B as predominant angiographic presentation. Correct diagnosis during index procedure was poor with only 33% accuracy. Nevertheless, a favourable trend over time was noted. Percutaneous coronary intervention success was 56%, as in 44% of patients initial stenting was complicated by progressive dissection. Overall, outcome was excellent with no reported fatalities. Conclusion SCAD remains an underdiagnosed subtype of ACS and the importance of increasing awareness amongst (interventional) cardiologists needs to be emphasised.

Spontaneous coronary artery dissection in Spain: clinical and angiographic characteristics, management, and in-hospital events

Introduction and objectivesSpontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome. The characteristics and in-hospital clinical course of patients with SCAD in Spain remain unknown. MethodsWe present data from consecutive patients included in the national prospective SCAD registry. Angiographic analysis was performed in a centralized core laboratory. ResultsBetween June 2015 and April 2019, we included 318 patients with SCAD (358 lesions) from 31 centers. Median age was 53 years, and 88% were women. The most frequent presentation was non–ST-segment elevation acute myocardial infarction (53%). The most frequently involved artery was the left anterior descending coronary artery (44%), predominantly affecting the distal segments (39%) and secondary branches (54%). Most lesions (62%) appeared on angiography as intramural hematoma, without double lumen. Conservative management was selected as the initial approach in most patients (78%). During the index admission, 6% of patients had a major adverse event and 4 patients (1.3%) died. Independent predictors of adverse events were initial management with percutaneous coronary intervention (OR, 5.97; P=.004) and angiographic presentation as intramural hematoma (OR, 4.96; P=.028). ConclusionsIn Spain, SCAD affects mainly middle-aged women. In most patients, the initial management strategy was conservative with excellent in-hospital survival. Initial management with percutaneous coronary intervention and angiographic presentation as intramural hematoma were related to the presence of in-hospital adverse events.Registered at ClnicalTrials.gov (Identifier: NCT03607981).