Emergency Cerebral Angiography Research Articles

Cerebral vasospasm after coil embolization for unruptured anterior communicating artery aneurysm: illustrative case.

BACKGROUNDCompared with several reports of cerebral vasospasm after clipping for unruptured cerebral aneurysm, only one study to date has reported cerebral vasospasm after coil embolization. Herein, the authors report a rare case of cerebral vasospasm after coil embolization for unruptured cerebral aneurysm.OBSERVATIONSA 58-year-old woman with an unruptured anterior communicating artery aneurysm was referred to our department. Stent-assisted coil embolization was performed for the aneurysm, and no obvious adverse events were observed on cerebral angiography obtained immediately after the operation. However, the patient developed mild headache and slight restlessness soon after the operation and new-onset disorientation, left hemispatial neglect, and left hemiplegia the day after the operation. Emergency brain magnetic resonance imaging and cerebral angiography indicated vasospasm in the right middle cerebral artery, and intra-arterial injection of fasudil hydrochloride hydrate was performed to dilate the middle cerebral artery. Blood flow in the middle cerebral artery immediately improved, and she was discharged without neurological deficits 8 days after the operation.LESSONSImmediate intervention is necessary to prevent cerebral infarction in patients with cerebral vasospasm, which may occur even after coil embolization for unruptured cerebral aneurysm.

149 Emergency Clot Retrieval and Stenting for Posterior Circulation Stroke

Abstract The current literature regarding the morphology and presentations of strokes due to basilar artery stenosis/occlusion is limited. This pathology is a rare cause of stroke and its management is not clearly decided in guidelines or published literature. Moreover, posterior circulation strokes are reported to be more devastating than anterior circulation. We present a case of a 68-year-old male who presented in an acute setting with reduced consciousness, myoclonic jerks, weakness and nausea due to a stroke from an occluded mid-segment basilar artery. MRI showed evidence of left cerebellar and right occipital infarcts. Emergent cerebral angiography was performed, and he was immediately treated by thrombectomy and stenting (Stryker Wingspan stent). The patient made a full recovery within one week and remained well at follow-up 3 months post-procedure. Emergency recanalization of basilar artery strokes, by clot retrieval and stenting, should be considered as a treatment option.

Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients

Introduction: Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO). Methods: Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome. Results: Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO <=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO >120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital. Conclusion: Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.

Should Cerebral Angiography Be Avoided within Three Hours after Subarachnoid Hemorrhage?

ObjectiveWhile the risk of aneurysmal rebleeding induced by catheter cerebral angiography is a serious concern and can delay angiography for a few hours after a subarachnoid hemorrhage (SAH), current angiographic technology and techniques have been much improved. Therefore, this study investigated the risk of aneurysmal rebleeding when using a recent angiographic technique immediately after SAH. MethodsPatients with acute SAH underwent immediate catheter angiography on admission. A four-vessel examination was conducted using a biplane digital subtraction angiography (DSA) system that applied a low injection rate and small volume of a diluted contrast, along with appropriate control of hypertension. Intra-angiographic aneurysmal rebleeding was diagnosed in cases of extravasation of the contrast medium during angiography or increased intracranial bleeding evident in flat-panel detector computed tomography scans. ResultsIn-hospital recurrent hemorrhages before definitive treatment to obliterate the ruptured aneurysm occurred in 11 of 266 patients (4.1%). Following a univariate analysis, a multivariate analysis using a logistic regression analysis revealed that modified Fisher grade 4 was a statistically significant risk factor for an in-hospital recurrent hemorrhage (p =0.032). Cerebral angiography after SAH was performed on 88 patients ≤3 hours, 74 patients between 3–6 hours, and 104 patients >6 hours. None of the time intervals showed any cases of intra-angiographic rebleeding. Moreover, even though the DSA ≤3 hours group included more patients with a poor clinical grade and modified Fisher grade 4, no case of aneurysmal rebleeding occurred during erebral angiography. ConclusionDespite the high risk of aneurysmal rebleeding within a few hours after SAH, emergency cerebral angiography after SAH can be acceptable without increasing the risk of intra-angiographic rebleeding when using current angiographic techniques and equipment.

Cardiac Imaging Within Emergency CT Angiography for Acute Stroke Can Detect Atrial Clots.

Cardiac embolism is presumed to cause a significant portion of cryptogenic strokes. Transesophageal echocardiography may detect intracardiac thrombi, but this remains a rare finding, possibly because remnant clots dissolve spontaneously or following thrombolysis. Cardiac imaging within cerebral CT angiography might offer an alternative method for thrombus detection within hyperacute stroke assessment. In a proof-of-concept study we analyzed records of patients aged ≥ 60 years that presented with suspected stroke and underwent extended cerebral CT angiography as part of their emergency assessment. CT imaging of patients with ischemic stroke or transient ischemic attack (TIA) and atrial fibrillation and of those with embolic strokes of undetermined source (ESUS) was reviewed for intracardiac clots and other cardiac or aortic pathology. Over a period of 3 months 59 patients underwent extended CT angiography for suspected stroke, 44 of whom received a final diagnosis of ischemic stroke or TIA. Of those, 17 had atrial fibrillation, and four fulfilled ESUS criteria. Thrombi were detected within atrial structures on CT angiography in three cases. In two ESUS patients complex atheromatosis of the proximal ascending aorta with irregular and ulcerating plaques was detected. Cardiac imaging within emergency cerebral CT angiography is feasible and can provide valuable diagnostic information in a patient group that might not routinely undergo transesophageal echocardiography. A small change to emergency assessment could potentially uncover cardioembolic pathology in cases that would have remained cryptogenic otherwise.

Interventional treatment of symptomatic intracranial in-stent restenosis

Objective: To assess the feasibility and safety of interventional treatment of symptomatic intracranial in-stent restenosis (SISR). Methods: Clinical data of 21 patients with SISR who underwent interventional treatment in the General Hospital of the PLA Rocket Force from January 2012 to May 2018 were retrospectively analyzed. Perioperative complications, angiographic and clinical follow-up results were recorded. Results: The success rate of treatment was 100%, including 21 lesions of SISR (7 at the V4 segment of the vertebral artery, 7 at the basilar artery, 5 at the M1 segment of middle cerebral artery, 2 at the internal carotid artery). The residual stenosis rate was preoperative 84±7, postoperative 30±14 respectively. Balloon angioplasty and stent implantation were performed in 10 patients (48.6%) and 11 patients (52.4%), respectively. After treatment, 1 patient experienced perforating event without neurological sequelae. Of the 11 patients (52.4%) completed angiography follow-up, 3 (3/11, 27.3%) ocurred restenosis and 1 was retreated. During clinical follow-up, 1 patients received intravenous thrombolysis for the symptom of acute cerebral infarction in territory of stenting artery, in-stent restenosis or occlusion was not demonstrated by emergency cerebral angiography. Conclusion: Interventional treatment of SISR is feasible and safe, however, further studies need to warrant the long-term effects.

Endovascular Treatment of a Temporal Bone Pseudoaneurysm Presenting as Bloody Otorrhea

Objective This case report is designed to illustrate an uncommon presentation of osteoradionecrosis (ORN) of the temporal bone and a treatment method for bloody otorrhea from a pseudoaneurysm of the internal carotid artery (ICA). Design This is a single patient case report Setting University of Missouri-Columbia Hospital and Clinics. Participants The report describes a patient with a history of hypopharyngeal squamous cell carcinoma (SCCA) who was previously treated with chemoradiation therapy and salvage bilateral neck dissections and then presented in a delayed fashion with profuse, episodic bloody otorrhea. Computed tomography (CT) was consistent with ORN of the temporal bone. The patient underwent emergent cerebral angiography. A pseudoaneurysm of the cervicopetrous ICA was confirmed to be the source of the patient's bloody otorrhea. The lesion was treated by endovascular sacrifice of the ICA using the two-catheter coiling technique. Results The patient had no neurologic sequelae or further bleeding after treatment. Conclusions Bloody otorrhea is an uncommon presentation of ORN. Sacrifice of the internal carotid can be considered as a treatment when the source is pseudoaneurysmal.

The impact of diabetes on the extent of pial collaterals in acute ischemic stroke patients

IntroductionThe threatened vascular territory in ischemic stroke is maintained by pial collateral circulation. Neovascularization varies among organ systems in diabetic patients. The effect of diabetes on the extent of pial...

Medial lenticulostriate artery aneurysm presenting with isolated intraventricular hemorrhage

Background:Isolated intraventricular hemorrhage (IVH) secondary to lenticulostriate artery aneurysm rupture is extremely rare. Thus, the diagnostic imaging modalities and therapeutic interventions utilized in the management of such cases are not clearly defined.Case Description:Here we describe a case of isolated or primary IVH (PIVH) in a 71-year-old woman presenting with severe headache. Emergent catheter cerebral angiography, performed after nondiagnostic computed tomography angiography (CTA), revealed the bleeding source to be a 4 × 2.6 mm distal medial lenticulostriate artery aneurysm that ruptured directly into the lateral ventricle. The poorly accessible location of the aneurysm for both endovascular and direct surgical treatment argued for conservative management. A good clinical outcome was obtained with rapid angiographic resolution of the ruptured aneurysm.Conclusion:Thus, lenticulostriate artery aneurysm rupture must be given diagnostic consideration in cases of isolated IVH. Emergent catheter cerebral angiography should be performed in cases such as this when noninvasive imaging is unrevealing. Conservative management may be a reasonable therapeutic option in patients with this kind of aneurysm, and spontaneous resolution can be observed.

Mechanical embolectomy for large vessel ischemic strokes: A cardiologist's experience

Large vessel acute ischemic stroke has a poor outcome. Intravenous (IV) thrombolysis is often contra-indicated and if given, usually ineffective. Mechanical embolectomy is an option in these patients and may be performed by an interventional cardiologist experienced in carotid interventions. Consecutive stroke patients were assessed by the stroke physician and, if eligible, referred for possible mechanical embolectomy using the Merci retriever. All procedures were done by a single cardiologist. Patient information, procedural characteristics and clinical outcomes at 90 days were collected by retrospective chart review. A total of 22 patients were referred for emergency cerebral angiography with 17 undergoing mechanical embolectomy. The mean National Institute of Health Stroke Scale (NIHSS) score was 20.1 and the mean stroke duration was 284 min. Recanalization was successful in 15 (88%) patients. Ten patients (59%) had a good outcome (modified Rankin Score ≤2 at 90 days) and four died (mortality 23%). Three patients had significant intra-cerebral hemorrhage. There were no other major adverse events. For patients with large vessel occlusion strokes where IV thrombolysis was either contra-indicated or had failed, mechanical embolectomy performed by an interventional cardiologist had a high recanalization rate with an acceptable clinical outcome and safety profile.

Lectin-like oxidized low-density lipoprotein receptor 1 and matrix metalloproteinase expression in ruptured and unruptured multiple dissections of distal middle cerebral artery: case report

Oxidized low-density lipoprotein receptor 1 (LOX1) is a critical factor for atherosclerosis in a variety of vascular diseases; however, its major role in cerebral arterial dissecting aneurysm is unclear. We present a case of remarkable contrast of LOX1 expression in ruptured and unruptured multiple middle cerebral artery dissections and discuss the correlation of LOX1 with matrix metalloproteinases (MMPs). A 59-year-old woman presented with subarachnoid hemorrhage associated with left temporal subcortical hematoma. Emergent cerebral angiography demonstrated aneurysmal dilatation at the origin of the left anterior temporal artery (ATA) and occlusion on the distal side of ATA. Infectious aneurysm was excluded. Intraoperative findings showed ruptured dissection of the left ATA and unruptured aneurysmal dilatation of another temporal branch of the left M1 portion. Both lesions were trapped by clips and resected. Histopathological examination confirmed that both ruptured and unruptured aneurysmal dilatations were diagnosed as arterial dissections. Immunohistochemical examination demonstrated remarkable expressions of LOX1, MMP-2, and MMP-9 in hypertrophic media outside the intima in ruptured dissection, on the other hand, those expressions in the intima and inside hypertrophic media in the unruptured dissection. This is the first report to reveal immunohistochemical findings of LOX1 and MMPs in multiple dissections of MCA. The contrast localization of LOX1 and MMPs might contribute to the fragility of the arterial wall layer of ruptured/unruptured arterial dissections.

Super-Selective Intra-arterial Magnesium Sulfate in Combination With Nicardipine for the Treatment of Cerebral Vasospasm in Patients With Subarachnoid Hemorrhage

To determine the safety and tolerability of super-selective intra-arterial magnesium sulfate in combination with intra-arterial nicardipine in patients with cerebral vasospasm after subarachnoid hemorrhage. Patients were treated in a prospective protocol at two teaching medical centers. Emergent cerebral angiography was performed if there was either clinical, ultrasound, and/or computed tomographic (CT) perfusion deficits suggestive of cerebral vasospasm. Intra-arterial magnesium sulfate (0.25-1 g) was administered via a microcatheter in the affected vessels in combination with nicardipine (2.5-20.0 mg). Mean arterial pressures (MAP) and intracranial pressures (ICP) were monitored during the infusion. Immediate and sustained angiographic and clinical improvement was determined from post-treatment angiograms and clinical follow-up. Angiographic and clinical outcomes were compared to two published case series that has used nicardipine alone. A total of 58 vessels were treated in 14 patients (mean age 42 years; 11 women) with acute subarachnoid hemorrhage. The treatment was either intra-arterial nicardipine and magnesium sulfate alone or in conjunction with primary angioplasty. Forty vessels (69%) had immediate angiographic improvement with intra-arterial nicardipine and magnesium sulfate alone and 18 vessels (31%) required concomitant balloon angioplasty with complete reversal of the vasospasm. Retreatment was required in 13 vessels (22%) and the median time for retreatment was 2 days (range 1-13 days). Nicardipine treatment resulted in the reduction of MAP (12.3 mmHg, standard error [SE] 1.34, P-value <0.0001) without any significant change in ICP. Magnesium sulfate infusion was not associated with change in MAP or ICP. Among 31 procedures, immediate neurological improvement was observed in 22 (71%) procedures. In 12 (86%) patients, there were no infarctions in the follow-up CT scan acquired between 24 and 48 h. No statistical significant difference was observed in angiographic and clinical outcome of patients treated with the combination therapy in comparison with historical controls treated with nicardipine alone. Administration of intra-arterial magnesium sulfate in combination with nicardipine was well tolerated in patients with subarachnoid hemorrhage and cerebral vasospasm without a significant change in MAP and ICP. The efficacy of this combination therapy should be evaluated in a larger, controlled setting.

Acute stroke intervention by interventional cardiologists

To report the technical success and clinical outcomes of catheter-based therapy (CBT) for acute ischemic stroke in patients ineligible for intravenous thrombolysis. Acute ischemic stroke is common but undertreated. CBT for acute ischemic stroke is a therapeutic option in selected patients who are not candidates for intravenous thrombolysis. Consecutive stroke patients who were ineligible for intravenous thrombolysis and underwent CBT were identified by retrospective chart review. Demographic information, National Institutes of Health Stroke Scale (NIHSS), procedural characteristics, and clinical outcomes during hospitalization and at 90 days follow up were collected. Experienced interventional cardiologists with the consultative support of stroke neurologists were on call for acute strokes. A total of 33 acute ischemic stroke patients underwent emergency cerebral angiography, with 26 patients undergoing CBT. Successful "culprit" artery recanalization was achieved in 23 (88%) of the 26 patients. In-hospital adverse events occurred in 4 (15%) patients, with intracerebral hemorrhage (ICH) (12%) representing the most common adverse event. The baseline NIHSS for patients who underwent intervention was 16.5 +/- 9.9 (median 16) and improved significantly to 9.9 +/- 8.7 (median 9) (P < 0.001) at hospital discharge. A modified Rankin score of two or less (indicating mild disability) was achieved in half (n = 13) of the CBT treated patients. All cause mortality at 90 days was 8% (2/26). In selected patients, CBT provided by qualified interventional cardiologists supported by stroke neurologists, offers a safe and effective option for patients with acute stroke who are not eligible for intravenous thrombolysis.

Intra-arterial thrombolysis using rt-PA in patients with acute stroke due to vessel occlusion of anterior and/or posterior cerebral circulation

The aim of our study was to evaluate the safety and efficacy of intra-arterial (IA) thrombolysis using recombinant tissue plasminogen activator (rt-PA) in patients with acute stroke due to occlusion in the anterior or posterior circulation. We retrospectively analyzed the clinical and radiological data of 88 consecutive patients with acute ischemic stroke who underwent emergency cerebral angiography for the purpose of subsequent IA thrombolysis. The neurological deficit on admission and discharge was graded using the National Institutes of Health Stroke Scale (NIHSS) score. Baseline computer tomography (CT) scans were examined for any signs indicative of cerebral ischemia. The angiographic findings were classified according to the Thrombolysis in Myocardial Infarction (TIMI) score for myocardial infarction. Follow-up CT scans were examined for hemorrhagic complication. Of the 88 patients who underwent IA thrombolysis, 63 presented with complete or partial arterial occlusion in the suspected perfusion area. In these 63 patients, the median NIHSS score dropped from 15 points on admission to 10 points at discharge. The recanalization rate was 52.6% for partial and complete reperfusion. In-hospital mortality was 20.6% (9.1% for carotid, 44.4% for basilar territory occlusion). Intracerebral bleeding (ICB) occurred in 38.6% of the patients with occlusion in the anterior circulation, resulting in these patients presenting a worse clinical outcome than those without ICB. Only minor extracranial bleedings occurred in 20.6% of patients. Patients with ICB had a significantly higher frequency of ischemic signs on the baseline CT scan. Occlusion of a cerebral artery is present in about 75% of the patients eligible for thrombolytic therapy. Intra-arterial thrombolysis using rt-PA in patients with acute ischemic stroke can achieve re-vascularization, although ICB remains the major risk factor affecting its efficacy.

Intra-arterial verapamil–induced seizures: case report and review of the literature

Background Intra-arterial verapamil infusion with or without balloon angioplasty is a common therapy for patients with hypertensive, hypervolemic, and nimodipine-refractory vasospasm following aSAH. Seizures occurring from IA infusion of verapamil are rare. Case Description A 24-year-old Korean-American woman presented with aSAH from the rupture of a 5-mm ICA bifurcation aneurysm. The aneurysm was secured with clip ligation through a craniotomy, and the patient was treated with HHH therapy in the neurosurgical ICU. Routine postoperative cerebral angiography was performed to confirm occlusion of the treated aneurysm and assess for vasospasm. In the first angiogram, vasospasm was detected in the supraclinoid portion of the ICA. Intra-arterial verapamil was started; during this treatment, the patient developed right-sided focal motor seizures. The infusion was terminated and the seizures were halted with midazolam. The patient's course was unremarkable until postoperative day 7, when she developed expressive aphasia, for which she was taken for emergent cerebral angiography under anesthesia. Marked focal spasm was identified in the distal supraclinoid ICA and the left A1. The patient was treated with 25 mg of superselective verapamil infusion. Upon emerging from anesthesia, her aphasia had resolved; however, 90 minutes after angiography, she experienced generalized seizures while she was in the ICU. Conclusions Seizures are a rare complication during cerebral angiographic procedures. Intra-arterial verapamil–induced seizures are infrequently reported. Cognizance for the potential of seizures to occur is advised during verapamil infusion for the treatment of refractory vasospasm in certain individuals.

Outcomes in Acute Ischemic Stroke Patients Without Angiographically Documented Arterial Occlusion

Patients with acute ischemic stroke who undergo emergent cerebral angiography for consideration of intra-arterial treatment and do not have an angiographically demonstrable occlusion pose a management dilemma. The authors reviewed their experience to determine the clinical out comes of patients with ischemic stroke evaluated within 6 hours of symptom onset in whom negative angiograms were obtained. A prospective registry was maintained for all patients (N = 56) who were considered for intra-arterial thrombolysis. Patients without angiographic arterial occlusion were not treated with thrombolytics, and data pertaining to clinical characteristics and neuroimaging findings was collected. Follow-up data were acquired through clinic visits or telephone interviews at 5.5 +/- 5.0 months (mean +/- SD), range 1 to 15 months, after onset of stroke. Of the 56 patients, no arterial occlusion was observed in 17 (30%) patients (mean age 65.8 +/- 13.0 years; 7 were men). The mean (+/- SD) baseline National Institute of Health stroke scale score was 10.2 +/- 7.1. Symptoms were referable to the anterior or posterior circulation in 76% and 18% of the patients, respectively; they could not be localized to either circulation in 6%. Follow-up neuroimaging studies demonstrated cerebral infarction in 12 of 14 patients. Eleven of the 17 had a favorable long-term recovery as assessed by the modified Rankin Scale (score 0 or 1). Five other patients had modified Rankin Scale scores of 3 (n = 1), 4 (n = 2), or 5 (n = 2). One patient died during the follow-up period. With regard to location of ischemic deficits, the highest rate of death or dependency was observed in patients with pontine infarction (three of four patients). Although the outcome following ischemic stroke in patients without angiographically documented occlusion appears to be better than that reported for patients with angiographically documented occlusion, death or disability is observed in at least one third of the patients. There fore, acute ischemic stroke in the absence of angiographic occlusion is not entirely a "benign" entity and can be particularly devastating when the brainstem is involved.

Outcomes in Acute Ischemic Stroke Patients Without Angiographically Documented Arterial Occlusion

Background and Purpose. Patients with acute ischemic stroke who undergo emergent cerebral angiography for consideration of intra-arterial treatment and do not have an angiographically demonstrable occlusion pose a management dilemma. The authors reviewed their experience to determine the clinical out comes of patients with ischemic stroke evaluated within 6 hours of symptom onset in whom negative angiograms were obtained. Methods. A prospective registry was maintained for all patients (N = 56) who were considered for intra-arterial thrombolysis. Patients without angiographic arterial occlusion were not treated with thrombolytics, and data pertaining to clini cal characteristics and neuroimaging findings was collected. Follow-up data were acquired through clinic visits or telephone interviews at 5.5 ± 5.0 months (mean ± SD), range 1 to 15 months, after onset of stroke. Results. Of the 56 patients, no arterial occlusion was observed in 17 (30%) patients (mean age 65.8 ± 13.0 years; 7 were men). The mean (± SD) baseline National Institute of Health stroke scale score was 10.2 ± 7.1. Symptoms were referable to the anterior or posterior circulation in 76% and 18% of the patients, respectively; they could not be localized to either circulation in 6%. Follow-up neuroimaging studies demonstrated cerebral infarction in 12 of 14 patients. Eleven of the 17 had a favorable long-term recovery as assessed by the modified Rankin Scale (score 0 or 1). Five other patients had modified Rankin Scale scores of 3 (n = 1), 4 (n = 2), or 5 (n = 2). One patient died during the follow-up period. With regard to location of ischemic deficits, the highest rate of death or dependency was observed in patients with pontine infarction (three of four patients). Conclusion. Although the outcome fol lowing ischemic stroke in patients without angiographically doc umented occlusion appears to be better than that reported for patients with angiographically documented occlusion, death or disability is observed in at least one third of the patients. There fore, acute ischemic stroke in the absence of angiographic occlusion is not entirely a “benign” entity and can be particularly devastating when the brainstem is involved.

Retrospective analysis of neurological outcome after intra-arterial thrombolysis in basilar artery occlusion

Background Basilar artery occlusion usually has a very poor outcome and is associated with a high mortality rate. Local intra-arterial thrombolysis may improve the clinical outcome and reduce mortality in the treatment of acute basilar artery occlusion. We evaluated the possible variables affecting recanalization and clinical outcome in patients with basilar artery occlusions undergoing thrombolytic therapy. Methods We analyzed retrospectively the clinical course and outcome of a series of 26 patients between 1998 and 2001. All patients who were examined within 24 hours after onset of symptoms underwent emergency cerebral angiography and subsequent intra-arterial thrombolysis. Three patients additionally received percutaneous transluminal angioplasty of underlying stenosis at the site of thrombosis. Results Outcome was good in 9 patients (34.6%) and poor in 17 (65.4%). Recanalization could be achieved in 24 patients (92.3%) and was not affected by age, sex, site of occlusion, etiology, thrombolytic drugs, or time interval. Good outcome was associated with younger age, good initial clinical condition, and no evidence of brain stem infarction. There was no association between the interval (greater or less than 6 hours) from the onset of symptoms until the end of thrombolysis and survival. Conclusions We confirm that intra-arterial thrombolysis reduces mortality in basilar artery occlusion. Young patients (<75 years) without any infarct in brain stem before the start of treatment seem to be the ideal candidates for thrombolysis. Basilar artery thrombosis could and should be reopened, even late (after 6 hours) after symptom onset.

Cerebral Vasospasm Following Subarachnoid Hemorrhage.

Cerebral vasospasm and related ischemic stroke continue to be significant complicating factors in the course of many patients with subarachnoid hemorrhage from berry aneurysm rupture. The risk of this well-recognized but poorly understood complication can be estimated on the basis of patient medical history, neurologic examination, and head CT findings. Every patient with possible risk needs specialized neurologic intensive care unit care after aneurysm obliteration. Surgical and pharmacologic wash-out of subarachnoid blood around the basal arteries, proper management of intracranial pressure and fluid status, hyponatremia, hypomagnesemia, and fever, as well as use of calcium channel blockers, have been considered helpful in patient management prior to and with the symptomatic vasospasm development. Transcranial Doppler (TCD) ultrasound is important in detecting vasospasm before the patient suffers ischemic neurologic deficit or infarct. Elevated TCD velocities often initiate the use of triple-H (HHH: hypertension, hemodilution, and hypervolemia) therapy and subsequently guide it. Up to the end of the first 3 weeks after subarachnoid hemorrhage and aneurysm obliteration, development of any focal neurologic deficit or mental deterioration, unless convincingly proven otherwise, is assumed to be from cerebral vasospasm. When a hemodynamically significant vasospasm in the arterial segments of clinical concern is suggested, emergency cerebral angiography with balloon dilatation angioplasty or intra-arterial infusion of vasodilating agents may be helpful in relieving ischemic symptoms.

Increased intracranial pressure resulting in a pulsatile aneurysm

sciousness disturbance and was transferred to our institution by ambulance. On arrival, the patient was comatose. Computerized tomography scanning revealed a right frontal intracerebral hematoma with intraventricular and subarachnoid hemorrhage. The patient underwent emergency cerebral angiography, which revealed slow pulsatile progression of carotid artery (CA) flow and an anterior communicating artery (ACoA) aneurysm that expanded and contracted in conjunction with the cardiac cycle (Fig. 1). The aneurysm volume increased 70% from that measured at systole to that measured at diastole (or, alternatively, a 230% increase in volume from that measured at diastole to that measured at systole). Because of his poor clinical condition, the patient was conservatively managed. He died 4 days later of irreversible brain damage. The volume of a ruptured aneurysm has been reported to increase by 51% between diastole and systole, compared with an increase of 17.6% in unruptured aneurysms.1 These data can be interpreted to indicate that volumes of ruptured and unruptured aneurysms are reduced 33.8% and 15%, respectively. When intracranial or local tissue pressure increases pathologically to reach the level of systemic blood pressure, the volume of an aneurysm may change drastically. Under these circumstances, the aneurysm could be overlooked on angiography because of its collapse or reduced volume.