Cerebral Digital Subtraction Angiography Research Articles

CAVE: Cerebral artery–vein segmentation in digital subtraction angiography

Cerebral X-ray digital subtraction angiography (DSA) is a widely used imaging technique in patients with neurovascular disease, allowing for vessel and flow visualization with high spatio-temporal resolution. Automatic artery–vein segmentation in DSA plays a fundamental role in vascular analysis with quantitative biomarker extraction, facilitating a wide range of clinical applications. The widely adopted U-Net applied on static DSA frames often struggles with disentangling vessels from subtraction artifacts. Further, it falls short in effectively separating arteries and veins as it disregards the temporal perspectives inherent in DSA. To address these limitations, we propose to simultaneously leverage spatial vasculature and temporal cerebral flow characteristics to segment arteries and veins in DSA. The proposed network, coined CAVE, encodes a 2D+time DSA series using spatial modules, aggregates all the features using temporal modules, and decodes it into 2D segmentation maps. On a large multi-center clinical dataset, CAVE achieves a vessel segmentation Dice of 0.84 (±0.04) and an artery–vein segmentation Dice of 0.79 (±0.06). CAVE surpasses traditional Frangi-based k-means clustering (P < 0.001) and U-Net (P < 0.001) by a significant margin, demonstrating the advantages of harvesting spatio-temporal features. This study represents the first investigation into automatic artery–vein segmentation in DSA using deep learning. The code is publicly available at https://github.com/RuishengSu/CAVE_DSA.

A deep learning method to identify and localize large-vessel occlusions from cerebral digital subtraction angiography.

An essential step during endovascular thrombectomy is identifying the occluded arterial vessel on a cerebral digital subtraction angiogram (DSA). We developed an algorithm that can detect and localize the position of occlusions in cerebral DSA. We retrospectively collected cerebral DSAs from a single institution between 2018 and 2020 from 188 patients, 86 of whom suffered occlusions of the M1 and proximal M2 segments. We trained an ensemble of deep-learning models on fewer than 60 large-vessel occlusion (LVO)-positive patients. We evaluated the model on an independent test set and evaluated the truth of its predicted localizations using Intersection over Union and expert review. On an independent test set of 166 cerebral DSA frames with an LVO prevalence of 0.19, the model achieved a specificity of 0.95 (95% confidence interval [CI]: 0.90, 0.99), a precision of 0.7450 (95% CI: 0.64,0.88), and a sensitivity of 0.76 (95% CI: 0.66, 0.91). The model correctly localized the LVO in at least one frame in 13 of the 14 LVO-positive patients in the test set. The model achieved a precision of 0.67 (95% CI: 0.52, 0.79), recall of 0.69 (95% CI: 0.46, 0.81), and a mean average precision of 0.75 (95% CI: 0.56, 0.91). This work demonstrates that a deep learning strategy using a limited dataset can generate effective representations used to identify LVOs. Generating an expanded and more complete dataset of LVOs with obstructed LVOs is likely the best way to improve the model's ability to localize LVOs.

Safety and efficacy of dynamic catheter-directed cerebral digital subtraction angiography for diagnosis of bowhunter syndrome spectrum disorders: A systematic review of the literature.

Dynamic catheter-directed cerebral digital subtraction angiography (dcDSA) is the gold standard for diagnosing dynamic vascular occlusion syndromes such as bowhunter syndrome (BHS). Nonetheless, concerns about its safety exist and no standardized protocols have been published to date. We describe our methodology and insights regarding the use of dcDSA in patients with BHS. We also perform a systematic literature review to identify cases of typical and atypical presentations of BHS wherein dcDSA was utilized and report on any procedural complications related to dcDSA. Our study included 104 cases wherein dcDSA was used for the diagnosis of BHS. There were 0 reported complications of dcDSA. DcDSA successfully established diagnosis in 102 of these cases. Thirty-eight cases were deemed atypical presentations of BHS. Fourteen patients endorsed symptoms during neck flexion/extension. In eight cases, there was dynamic occlusion of bilateral vertebral arteries during a single maneuver. Three patients had multiple areas of occlusion along a single vertebral artery (VA). An anomalous entry of the VA above the C6 transverse foramen was observed in four patients. One patient had VA occlusion with neutral head position and recanalization upon contralateral lateral head tilt. Our study highlights the safety and diagnostic benefits of dcDSA in characterizing the broad spectrum of BHS pathology encountered in clinical practice. This technique offers a powerful means to evaluate changes in cerebral blood flow and cervical arterial morphology in real time, overcoming the constraints of static imaging methods. Our findings pave the way for further studies on dcDSA to enhance cross-sectional imaging methods for the characterization of BHS and other dynamic vascular occlusion syndromes.

Utilization and reimbursement of diagnostic cerebral angiograms: A Medicare trends analysis from 2013 to 2020.

Increasing life expectancy has caused growing concern about maintaining viable neurointerventional practices due to altered Medicare payment structures. This study analyzes the financial trends of three common diagnostic tests for cerebrovascular disease: cerebral digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). Medicare Part B National Summary Data files from 2013 to 2020 were queried by Current Procedural Terminology (CPT) codes for DSA (36221-36228), CTA (70496, 70498), and MRA (70544-70547, 70549). Inflation-adjusted charges and reimbursement were calculated using the U.S. City Average Consumer Price Index for Medical Services. Regression analysis was performed on charges, reimbursement, and volume. A total of 1,519,245 diagnostic procedures were conducted between 2013 and 2020 (782,370 angiograms, 246,603 CTAs, and 490,272 MRAs). A total of $41.005 million was reimbursed by Medicare in 2020 for these diagnostic procedures. The annual percent change in volume for all procedures was -2.90%. From 2013 to 2020, inflation-adjusted: Medicare total physician reimbursement decreased for cerebral angiograms (-4.12%, p = 0.007), CTAs (-2.77%, p = 0.458), and MRAs (-9.06%, p < 0.001). Procedural volume billed to Medicare decreased for cerebral angiograms (-4.63%, p = 0.007) and MRAs (-2.94%, p = 0.0.81) and increased for CTAs (+3.15%, p = 0.004). The greatest increase in Medicare reimbursement (+66.75%) came from CPT code 36224, "place catheter carotid artery", and the greatest decrease in Medicare reimbursement (-8.66%) came from CPT code 36226, "place catheter vertebral artery." This study provides an analysis of Medicare reimbursement trends for routine cerebrovascular angiogram techniques. The findings highlight a decline in Medicare reimbursements for neurointerventionalists.

Contrast Induced Encephalopathy: Case Report and Review of The Literature

Background: Contrast Induced Encephalopathy is a known but rare complication of endovascular procedures. Patients show neurologic symptoms mimicking a stroke and include visual disturbances, motor or sensory deficits, headache, seizures, memory loss, confusion, aphasia, and coma. Irreversible neurological symptoms are rare and fatal encephalopathy is even more so. Case Report: In this article we present a case of a 75-year-old female patient who showed neurological symptoms mimicking a stroke post cerebral Digital Subtraction Angiography that was done with Iohexol as a contrast agent, as a diagnostic work up to rule out a ruptured aneurysm. Further investigations showed no arterial spasms nor dissection. Symptoms reappeared after the second contrast administration but completely resolved after the administration of steroids and fluids. Conclusion: Contrast Induced Encephalopathy should be further investigated with imaging to rule out other thromboembolic or hemorrhagic causes. Treatment via the administration of steroids and fluids have shown to be effective with complete remission of symptoms.

Cerebral thromboembolic complications during cerebral angiography and their risk factors in different subgroups: Analysis of 2,457 procedures.

Diagnostic cerebral digital subtraction angiography (DSA) is an invasive examination that involves catheterization of the major supra-aortic arterial trunks and evaluation of intracranial vessels for diagnostic purposes. Although considered the gold standard method for investigating cerebrovascular diseases, DSA carries measurable and potentially serious complication rates. This report describes the frequency of neurological and non-neurological complications of DSA performed in five hospitals in the state of São Paulo, Brazil, and analyzes them in different disease subgroups. It has a special focus on thromboembolic cerebral complications. We retrospectively reviewed clinical records of all adult patients who underwent DSAs between January 2019 and December 2022. Demographic variables, DSA reports, CT/MRI reports, and clinical follow-up notes were reviewed. Twenty-four patients experienced some type of complication among 2,457 diagnostic DSAs (0.97%). Thromboembolic complications were recorded in 9 patients (0.36%), and access site hematomas larger than 5cm were registered in six patients (0.24%). There was a statistical trend for thromboembolic complications in patients with cervical and/or intracranial atherosclerosis (p = 0.07), but age was not associated with them (p = 0.93). Patients who received heparin had lower rates of embolic complications than those who did not receive it, but there was no statistically significant difference (p = 0.17). Intravenous administration of heparin showed a trend toward significance with groin hematoma (p = 0.10). Diagnostic catheter DSAs have low complication rates.

Cerebral Proliferative Angiopathy as the Cause of Symptomatic Epilepsy in a Young Adult Male: A First Case Report from Indonesia

Background: Cerebral proliferative angiopathy (CPA) is a rare and distinct vascular malformation that was once considered a subset of cerebral arteriovenous malformation (AVM). Due to its relatively benign course with no distinctive clinical feature, CPA may often be overlooked and misdiagnosed with other diseases. We report a case of CPA as the underlying cause of symptomatic epilepsy. Case: A 31-year-old male presented to the outpatient clinic with a history of focal to bilateral tonic-clonic seizure for 2 years. Following conservative management with an oral antiepileptic agent, the seizure frequency significantly decreased from once daily to once or twice monthly. The patient was lost to follow-up; however, he was incidentally referred back to our clinic two years later for further evaluation. A head Magnetic Resonance Imaging and Magnetic Resonance Angiography revealed a suspicion of giant AVM in the left hemisphere. Cerebral digital subtraction angiography (DSA) was performed and revealed a CPA in the left frontal area. The patient was managed conservatively and during the 6-month follow-up period, the patient did not have any seizures. Discussion: In young adults, seizures may be caused by an underlying vascular abnormality. Cerebral DSA remained the gold standard for distinguishing various etiologies of vascular malformation, including CPA. Conservative treatment using oral antiepileptic agents was effective in controlling the seizure frequency in CPA. However, a complete diagnostic evaluation is still warranted to determine the most appropriate treatment, revealing some peculiar and unexpected etiologies in the process.

Digital subtraction angiography findings of stroke in young adult population: a multi-center record-based study

BackgroundStroke is one of the main causes of disability, in which nearly 2/3 of survivors experience disability and interferes with the patient’s daily functional activities. Hypertension, dyslipidemia, obesity, and smoking habits are the main causes of stroke in young adults. Vascular abnormalities are also risk factor for stroke in young adults. Advanced imaging examinations such as cerebral digital subtraction angiography (DSA) can provide a clear picture of the vasculature of the blood vessels of the human brain and provide a real-time picture of the hemodynamic status, blood flow and collateral circulation of the cerebral vessels.ResultsThere were approximately 999 patients who had DSA cerebral examination during the study period. The total young adult population was 147 [92 males (62.4%) and 55 females (37.6%)]. There were 82 patients with ischemic stroke (60.7%). The main etiology of ischemic stroke in this study was intracranial atherosclerotic disease (ICAD) [44 (53.65%)]. The young adult population had 53 hemorrhagic stroke patients (39.3%). The main cause of hemorrhagic stroke is hypertensive vasculopathy (41.5%), followed by a ruptured cerebral arteriovenous malformation (CAVM) (37.7%). There were 12 patients with cerebral sinus venous thrombosis (CSVT). Headache is the main complaint of patients with venous stroke, followed by seizures and hemiparesis. The transverse sinus is the most common site for occlusion (66.7%).ConclusionThis study describes the characteristics and prevalence of stroke in young adults based on the results of cerebral DSA examination. Stroke in young adults is not uncommon. Several traditional risk factors in old age are now found in young people. Lifestyle modification is needed to reduce the prevalence of stroke in young adults.

Angiographic Evaluation of the Feeding Artery in Skull Base Meningioma.

To identify the characteristics of feeding arteries in skull base meningioma including location and prevalence, we evaluated the distributions and types of feeding arteries in skull base meningioma by cerebral angiography and assessed relationships to tumor attachment. We enrolled patients with skull base meningioma who underwent MRI and cerebral digital subtraction angiography (DSA), from September 2015 to October 2022. Subjects comprised 115 patients (32 males, 83 females; mean age, 52.7) with 117 meningiomas, showing tumor attachments around the "cavernous sinus to the upper part of the clivus" (Area 1), "lower part of the clivus to foramen magnum" (Area 2), and "tentorium around the petrous bone" (Area 3). Frequent arteries, such as the dorsal meningeal artery (DMA), the ascending pharyngeal artery (APA), the tentorial artery (TA), and the petrosal branch (PB) of the middle meningeal artery (MMA) were analyzed in terms of their associations with tumor attachment to Areas 1-3. Meningiomas with the DMA as a feeding artery correlated with tumor attachment to Area 1 (p < 0.001). Meningiomas with the APA correlated with tumor attachment to Area 2 (p < 0.001). Meningiomas with the TA correlated with tumor attachment to Area 3 (p < 0.001). The PB correlated with Area 3 (p < 0.05). Our study founded that visualization of these arteries correlated well with specific areas. These arteries were also the main feeders in each type of skull base meningioma.

Prosedur Pemeriksaan Digital Subtraction Angiography (DSA) Vena Cerebral Dengan Akses Transradial Pada Kasus Cerebral Venous Thrombosis (CVT)

Background: Cerebral venous thrombosis (CVT) is a form of stroke when blood clots develop in the (venous sinus) of the brain. This condition causes the blood that flows into the brain to be unable to flow out. This can cause reduced blood flow to the brain and damage or kill brain cells if not treated properly. The research aims to determine the digital subtraction angiography (DSA) examination procedure of cerebral veins with trans-radial access in cases of cerebral venous thrombosis (CVT). Method: This type of research is qualitative research with a case study approach. Data was collected on July 20 2023.The research subjects were doctors, interventional radiology doctors, and scrub nurses. By conducting observations, interviews and documentation of the implementation team involved. Results: From the results of observations, documentation and interviews with the implementing team, results were obtained regarding the Cerebral Vein Digital Subtraction Angiography (DSA) examination procedure with transradial access in cases of Cerebral Venous Thrombosis (CVT), including several sub-topics. The Cerebral Digital Subtraction Angiography (DSA) examination procedure with Transradial access is the right action for patients regarding immobility and shorter hospital stays. Conclusion: The Cerebral Vein Digital Subtraction Angiography (DSA) examination procedure with transradial access in cases of Cerebral Venous Thrombosis (CVT) includes patient preparation, tools and materials, examination techniques and post-action care. The Cerebral Vein Digital Subtraction Angiography (DSA) examination procedure with Transradial access is the right action for patients regarding patient immobility and shorter duration of hospital stay. The implementation team consists of a radiology specialist, a scrub nurse and no radiographers involved in the DSA examination room.

Mechanical thrombectomy after 6 hours from the symptoms onset in acute ischemic stroke in the carotid basin due to the large vessel occlusion

Objective ‒ to assess the safety and effectiveness of mechanical thrombectomy performed no later than 6 years after the onset of symptoms in patients with ischemic stroke in the carotid basin due to occlusion of a large vessel.Materials and methods. The results of a retrospective analysis of the register of patients who received treatment at the Scientific-practical Center of endovascular neuroradiology NAMS of Ukraine in the period from 01.01.2021 to 25.12.2022 for acute ischemic stroke in the carotid basin due to occlusion of a large vessel of the brain are presented. We selected 106 patients who were functionally independent before stroke (0‒2 points on the modified Rankin Scale) and who underwent arterial puncture on the operating table for mechanical thrombectomy later 6 hours after appearance the first symptoms of stroke. The age of the patients ranged from 27 to 86 years (average age ‒ 67.3 years). There were 49 (46.2 %) men, 57 (53.8 %) women.All patients underwent multimodal neuroimaging: computed tomography (CT) of the brain, CT angiography of extracranial and intracranial cerebral arteries, or digital subtraction cerebral angiography. Quantitative assessment of initial ischemic changes in the middle cerebral artery basin was performed using the ASPECTS (Alberta Stroke Program Early CT Score). The ACG scale (American Society of Interventional and Therapeutic Neuroradiology collateral grading) was used to assess collateral blood flow.Results. The main subtype of ischemic stroke was cardioembolic ‒ 76 (71.7 %) observations. The atherothrombotic subtype occurred in 20 (18.9 %) patients. Other subtypes (cryptogenic, dissection) were diagnosed in 10 (9.4 %) cases. Occlusions in the middle cerebral artery basin were diagnosed in 69 (65.1 %) cases, tandem occlusions (internal carotid artery ‒ middle cerebral artery) were detected in 28 (26.4 %) patients. Isolated thrombosis of the internal carotid artery (I-occlusion) and T-occlusion were noted in 9 (8.5 %) observations. Well-defined collaterals (ACG score 3–4) were observed in 78 (73.6 %) patients. The group of patients with mild collateral compensation (ACG 2) accounted for 28 (26.4 %) cases. In patients within 6 to 24 hours after the onset of stroke symptoms, high-quality reperfusion (eTICI 2b-3) was achieved in 90 (84.9 %) observations. Intraoperative complications were recorded in 13 (12.3 %) cases. Among them, embolism of new arterial pools was noted in 10 (9.4 %) patients, dissection of the internal carotid artery in 1 (0.9 %) and intracranial hemorrhage due to perforation/rupture of the artery in 2 (1.9 %). Good functional results of treatment (mRS 0–2) after 90 days were observed in 54 (50.9 %) patients.Conclusions. Mechanical thrombectomy performed later than 6 hours after the onset of symptoms in acute ischemic stroke in the carotid basin due to large vessel occlusion in patients with good neuroimaging results is safe and effective.

Drawing time-density curve with Fiji/ImageJ: An alternative approach for parametric coding of cerebral digital subtraction angiography

BackgroundQuantitative spatiotemporal analysis of digital subtraction angiography could support clinical decision making for the management of cerebral vascular disease. However, there is a lack of free and user-friendly applications. The objective of our study is to devise a free and simple solution for parametric coding of digital subtraction angiography. New MethodBy driving the time-density curves in the region of interest, the digital subtraction angiography images were color-coded and quantitatively analyzed using fully open-source and free software (Fiji/ImageJ). The similarity factor (f2) was used to compare the resolution profiles between time-density curves generated with commercial software on the Siemens workstation (syngo iFlow, Siemens Healthcare, Berlin, Germany) and our method. Results and comparison with existing methodSixteen patients diagnosed with acute ischemic stroke resulting from acute occlusion of the distal internal carotid artery or the first segment of the middle cerebral artery were selected for analysis. Angiography images were successfully processed with syngo iFlow and Fiji/ImageJ. The images processed with Fiji/ImageJ provided excellent anatomic and hemodynamic details. In all patients, the similarity factor (f2) values of the time-density curves derived from the same region of interest were 99.90 (range 99.85–99.95). ConclusionsThe ImageJ/Fiji software provides a user-friendly and free alternative for parametric coding of digital subtraction angiography.

Preoperative cerebral angiography nearly doubles the rate of diffusion-weighted imaging lesion detection following minimally invasive surgery for intracerebral hemorrhage

BackgroundDiffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of...

Changes in blood and renal function in patients after cerebral digital subtraction angiography.

Describe the incidence of contrast-induced acute renal injury (CI-AKI) and the changes in hematocrit in a cohort of patients undergoing elective cerebral digital subtraction angiography (DSA). In this prospective study, patients undergoing cerebral DSA were assessed for hematocrit level and CI-AKI risk factors before the procedure and for developing CI-AKI 72h after exposure to the contrast media. Among 215 patients (109 men, mean age 36.6 years). The most frequently found CI-AKI risk factor was hypertension. There were no cases of permanent renal impairment after 14 days. Significant changes were observed in hematocrit (45.7±4.9, vs. 44.5±4.6, p=0.001), estimated creatinine clearance (129.7±48.3, vs. 123.1±40.5, p=0.002), and serum creatinine (0.72±0.19, vs 0.74±0.18, p=0.031). The mean change in serum creatinine 72h after contrast administration was +0.27±0.10mg/dL (p<0.05). The incidence of CI-AKI after elective cerebral DSA was 1.4%. A significant decrease in hematocrit was observed up to 72h after the procedure.

Intracerebral hemorrhage and ischaemic stroke due to Moyamoya disease in young patients: a case report

Link of Video Abstract: https://youtu.be/DWVi34rPNOg Background: Moyamoya disease (MMD) is a non-atherosclerotic cerebrovascular disorder characterized by progressive stenosis of the distal part of the internal carotid artery (ICA), thus forming an abnormal vascular network in the base of the brain. MMD is often found in women. The common symptoms of MMD are migraine, epilepsy, recurrent transient ischemic attack (TIA), ischemic stroke, and intracerebral hemorrhage. Stroke at young onset has challenges in looking for risk factors and etiology. A detailed examination is needed to prevent recurrent strokes. Case Presentation: Male 17-year-old complained of a throbbing headache on the right side for 5 months, with a numeric rating scale (NRS) 4. The headache duration was 24-72 hours, with a frequency of 1-2 times a month. Complaints are exacerbated by activity and improve when taking over medication. 2 months after the first onset, he felt severe headache with NRS 7, accompanied by weakness and tingling on the left side. All his laboratory results were within normal limits. Cerebral Digital Subtraction Angiography (DSA) results showed severe stenosis at the base of the right ICA bifurcation segment accompanied by slow flow at the right middle cerebral artery (MCA) and severe stenosis at the base of the left ICA accompanied by cross-filling to the contralateral anterior cerebral artery (ACA). Cortico-cortical collaterals were obtained from the posterior cerebral artery (PCA) branch covering the MCA area. The patient was diagnosed with MMD. Conclusion: MMD is a rare cerebrovascular disease that can be a risk factor for stroke at a young age. Diagnosis and evaluation of the collateral system need to be carried out through cerebral angiography so that the selection and consideration of appropriate management of recurrent stroke attacks can be carried out.

Analysis of risk factors associated with cerebral angiography headache

Despite previous studies indicating a moderate/high incidence of angiography headache (AH), there is still limited data about the risk factors associated with its occurrence. The present study aimed to assess the associations among demographic, clinical, and technical characteristics of cerebral digital subtraction angiography (DSA) and the occurrence of AH. Cross-sectional analytical observational study with a sample comprised of individuals with a recommendation for elective DSA. Clinical interviews were conducted to assess the occurrence of AH, using a standardized questionnaire. Among 114 subjects, the mean age was 52.8 (±13.8) years old, 75.4% (86/114) were women, 29.8% (34/114) had a history of migraines, and 10.5% (12/114) had chronic headaches. The overall frequency of AH was 45.6% (52/114). Of those, 88.4% (46/52) underwent 3D angiography, 7.7% (4/52) underwent aortography, and 1.9% (1/52) underwent both procedures. There was a statistically significant association between AH and previous history of migraine (odds ratio [OR]: 4.9; 95% confidence interval [CI] 1.62-14.7; p = 0.005) and 3D angiography (OR 6.62; 95%CI: 2.04-21.5; p = 0.002). 3D angiography is strongly associated with the occurrence of AH, which has never been reported before. The association between a previous history of migraine and AH confirms the results of previous studies.

Abstract Number ‐ 219: Spinal cord infarct in young: Fibrocartilaginous Embolism with Occlusion of Anterior Spinal Artery

Introduction Spinal cord infarctions are rare and account for fewer than 1% of all strokes. Diagnosis is usually established by clinical symptoms of sudden onset paraplegia and sensory dysfunction along with radiographic evidence of a non‐enhancing, diffusion‐restricted T2 hyperintense lesion on spinal cord MRI. We describe an interesting case of anterior spinal artery infarct from suspected fibrocartilaginous embolus from intervertebral disc. Methods Case report. Demographics and clinical history were obtained by chart review. MRI and cerebral angiogram images were reviewed and compared to radiology reports. Results 21‐year‐old female with no prior medical history presented with sudden onset headache, bilateral arm tingling, and neck stiffness that rapidly progressed within the hour to quadriplegia with numbness below the T2 sensory level. She continued to worsen, developed respiratory failure and required intubation. MRI of the cervical cord revealed a longitudinally extensive, non‐enhancing, diffusion‐restricted lesion extending from the bilateral medial medulla to the ventral spinal cord at C5/6 vertebral level. Cerebral and spinal digital subtraction angiography was notable for non‐opacification of the cervical anterior spinal artery. She had extensive work up for dissection, vasculitis, hypercoagulable state, autoimmune conditions that were all negative. However, there was a diminished T2 signal in her C5‐6 intervertebral disc with subtle loss of intervertebral disc space concerning for disc compression, likely related to her job requiring intensive heavy lifting. It was surmised that she developed a ventral cervical cord infarct secondary to fibrocartilaginous embolization and occlusion of anterior spinal artery, from recent mechanical compression of her C5‐6 disc. Cases of spinal cord infarcts following mechanical trigger, such as heavy lifting or falls, with histopathological confirmation of fibrocartilaginous material in the vasculature postmortem are well reported. It is postulated as a mechanism of spinal cord infarct in young patients that compressive forces on the intra‐vertebral body trigger embolization of nucleus pulposus material through persistent nuclear anastomoses to the spinal circulation. Conclusions Ischemic infarct should be considered in the differential diagnosis for sudden onset of symptoms localizable to spinal cord, especially when spinal MRI shows restricted diffusion in a vascular distribution. Demonstrating non‐opacification of the anterior spinal artery on digital subtraction angiography confirms the diagnosis. In case of negative work up for spinal cord infarct, the presence of an abnormal signal in the intervertebral disc on MRI may suggest fibrocartilaginous embolism as a mechanism of infarction in young patients.

Importance of Instant Thrombectomy to Treat Cerebral Vessel Occlusion During TAVI in Third World Country

Background: Transcatheter aortic valve implantation (TAVI) is considered to be one of the treatments for symptomatic severe aortic stenosis. This procedure has been associated with cerebrovascular events be it thromboembolic or hemorrhagic in nature that increase the periprocedural mortality and morbidity. Strokes post TAVI are mostly ischemic in origin; they can be either due to symptomatic or silent emboli. These thromboembolic events may occur during the procedure or up to 2 months after the procedure. In the acute setting, especially during the procedure, immediate intervention is crucial for better patient outcome. Mechanical thrombectomy is the best treatment modality for immediate revascularization and stroke prevention. Case description: We present a case of a patient who developed symptomatic signs of hypoperfusion during the procedure that required an urgent mechanical thrombectomy in a third world country. The patient didn’t undergo CT imaging and wasn’t transferred to the brain angiography suite; the procedure was done using the x-ray machine and in the cardiology catherization lab which lacks proper equipment to do cerebral DSA (Digital subtraction angiography). This case is the 8th to be reported in the literature where mechanical thrombectomy was done on the table during a TAVI procedure. Based on this case and the literature review, we will propose an algorithm for dealing with similar cases. Conclusion: We highlight the importance of instant thrombectomy that should be done in a patient suffering from a thromboembolic event while performing TAVI procedure. Using the same endovascular access, in the same setting in the cardiac catherization lab to assess thrombus location, even if done sub-optimally without DSA, in correlation with patient’s symptoms, without taking the patient to perform a CT scan, is life saving and guarantees quick reperfusion after clot aspiration with clinical improvement afterwards and better patient outcome.

Prognostic Factors for Parasagital Meningiomas Recurrence

the study is relevant due to high prevalence of this type of pathology. Meningiomas account for 18% to 34% of all primary brain tumors. Parasagital meningiomas occur in 24.3% to 38.6% of cases. Despite their predominantly benign nature, parasagital meningiomas are more likely to recur/continue growing than meningiomas in other areas (18% to 40%). The key purpose of the study was to analyze the prognostic factors of parasagital meningiomas recurrence/continued growth, which will eventually improve surgical treatment outcomes. We conducted a retrospective and prospective analysis of 199 parasagital meningioma patients who were treated in Mechnikov Dnipropetrovsk Regional Clinical Hospital, Dnipropetrovsk Regional Council, from 2000 to 2021 inclusive. This article is based on a comparative analysis of the results of examination and surgical treatment and further analysis of pathohistological conclusion in two study groups. The first group included 180 (90.5%) patients with no recurrence/continued growth and second group included 19 (9.5%) patients with detected postoperative parasagital meningioma (PM) recurrence/continued growth. The selected patients were analyzed for demographic data (gender, age); computed tomography and magnetic resonance brain imaging results before and after adding an intravenous contrast (in terms of key characteristics); angiographic studies data (computed tomography angiography/selective digital subtraction cerebral angiography); surgical radicality; pathohistological conclusions; recurrence-free period duration (one to 20 years after the surgery). In the follow-up period, 19 (9.5%) patients had PM recurrence/continued growth. In the first year after the surgery, only 2 of those patients had continued PM growth; within 5 years (60 months), 12 patients; within 10 years, 17 patients; the percentage of no- recurrence patients, based on censored data (recurrence-free survival), was 99.0% (95% CI, 97,6-100), 93,1% (95% CI, 89.3-96.9). and 87.5% (95% CI, 81.6-93.4) in the above follow-up periods. The actual median time to recurrence in our study was 44.1 (25.7; 85.4) months. It means that the majority (12 of 19 patients; 63.2%) of continued PM growth was detected within 5 years after the surgery. The last case of PM recurrence was diagnosed after 13 years (154.5 months) of the follow-up. Thus, recurrence-free 5- and 10-year survival in PM patients is as follows: in case of total tumor removal (Simpson I), 96.0% and 85.5%, respectively; in case of non-radical removal (Simpson II-V), 88.9% (p&lt;0.05) and 81.9% (p&lt;0.05), respectively. At the same time, non-radical surgery in type I-II SSS invasion by the PM reduces 5- and 10-year recurrence-free survival to 86.6% (p&lt;0.01) and 78.3% (p&lt;0.01), respectively; in case of tumor size of up to 54 mm, the indicators are 95.5% and 91.4%; with tumor size &gt;54 mm, they are as low as 87.5% (p&lt;0.001) and 72.5% (p&lt;0.001); in case of type I-III or V-VI SSS damage according to M. P. Sindou and J. E. Alvernia, 94.0% and 89.1%; and in case of type IV invasion, 66.5% (p&lt;0.01) and 43.5% (p&lt;0.001); in female patients, 95.2% and 88.5%; in male patients, 84.8% (p&lt;0.05) and 73.0% (p&lt;0.01). According to the Cox regression proportional hazards model, the relative risk of tumor recurrence/continued growth increases by: 7.04 times (95% CI, 2.33-21.2) in case of initial PM size &gt;54 mm (p&lt;0.001); 5.57 times (95% CI, 1.27-24.34) in case of non-radical (Simpson II-V) tumor removal during primary intervention (P&lt;0.05); 10.1 times (95% CI, 1.31-78.1) in case of type I-II SSS invasion by the PM or incomplete (Simpson II-V) tumor removal (p&lt;0.05); 3.25 times (95% CI, 1.32-8.02) in male patients (p&lt;0.01); 3.33 times (95% CI, 1.10-10.12) in case of type IV SSS invasion (according to M.P. Sindou and J.E. Alvernia) (p&lt;0.05). Adequate analysis of the results obtained will help the neurosurgeons plan the optimal surgery volume and ensure further postoperative recurrence-free period and improved long-term treatment outcomes.

Flow Diversion as Destination Treatment of Intracranial Mycotic Aneurysms: A Retrospective Case Series.

Mycotic aneurysms represent a rare type of intracranial aneurysm. Treatment options usually consist of coiling, clipping, or liquid embolization. Data regarding outcomes after flow diversion of mycotic aneurysms are sparse. To present a single-center case series regarding our experience with FD as definitive treatment for ruptured mycotic aneurysms initially treated with coil embolization. We retrospectively reviewed a prospectively maintained database of all cerebrovascular procedures performed at a single institution between 2017 and 2021 for cases that used FD for the management of intracranial mycotic aneurysms. Prospectively collected data included patient demographics, medical history, rupture status, aneurysm morphology, aneurysm location, and periprocedural complications. The main outcomes included neurological examination and radiographic occlusion rate on cerebral digital subtraction angiography. Three patients with 4 ruptured mycotic aneurysms that were initially treated with coil embolization were identified that required retreatment. The aneurysms were located along the middle cerebral artery bifurcation (n = 2), posterior cerebral artery P1/2 junction (n = 1), and basilar artery apex (n = 1), which all demonstrated recurrence after initial coil embolization. Successful retreatment using flow diverting stents was performed in all 3 patients. At the last angiographic follow-up, all aneurysms demonstrated complete occlusion. No patients suffered new periprocedural complications or neurological deficits after FD. Flow-diverting stents may be an effective treatment option for intracranial mycotic aneurysms that are refractory to previous endovascular coiling. Future studies are warranted to establish the associated long-term safety and clinical efficacy.