Search

Competing Interests: There are no conflicts of interest.

Background: The Raymond-Roy classification has been the standard for neck recurrences following endovascular coiling with three grades. Several modified classification systems with subdivisions have been reported in literature but it is unclear whether this adds value in predicting recurrence or retreatment. Our aim is to assess if these subdivisions aid in predicting recurrence and need for retreatment., Methods: A retrospective review of all patients undergoing endovascular coiling between 2013 and 2014. Patients requiring stent assistance or other embolization devices were excluded from the study. The neck residue was graded at time of coiling on the cerebral angiogram and subsequent 6, 24, and 60 months MRA. Correlation between grade at coiling and follow-up with need for subsequent retreatment was assessed., Results: Overall, 17/200 (8.5%) cases required retreatment within 5 years of initial coiling. 4/130 (3.1%) required retreatment within 5 years with initial Grade 0 at coiling, 6/24 cases (25%) of those Grade 2a, 4/20 cases (20%) Grade 2b, 3/8 (38%) Grade 3, and none of those with Grade 1. Large aneurysms ≥11 mm had an increased risk of aneurysm recurrence and retreatment. About 9.7% of ruptured aneurysms required retreatment versus 4.4% for unruptured. About 55% of carotid ophthalmic aneurysms were retreated., Conclusion: Although the modified classification system was significantly predictive of progressive recurrence and need for retreatment, no significant difference between the subdivisions of Grade 2 was observed. Similar predictive value was seen when using the Raymond-Roy classification compared to the new modified, limiting the usefulness of the new system in clinical practice., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Surgical Neurology International.)

Objectives: This retrospective study was aimed at assessing our results of endovascular management in vein of Galen aneurysmal malformation (VGAM)., Materials and Methods: This is a retrospective study of 26 patients of VGAM who underwent endovascular treatment between 1998 and 2012. All patients underwent trans-arterial embolization. Of 26 patients, 23 were treated using n -butyl cyano acrylate (Glue), while 3 out of 26 patients were treated using the ethylene vinyl alcohol (EVOH) copolymer., Results: Ages of the treated patients ranged from 1 day to 18 years of age. Of the patients treated, 17 were males and 9 were females. Around 15 of the VGAMs were of the mural variety and 11 were choroidal in nature. A good outcome was seen in 22/26 (85%) of the patients. Complications were seen in total in 7/26 patients (26.92%) of which 3/26 (12%) has a fatal outcome., Conclusion: Endovascular embolization for VGAMs is highly efficacious and has helped create a population of VGAM survivors in this condition, which until only a few decades ago caused high mortality and morbidity.

Subpial hematoma is a rare type of intracranial hemorrhage with a poor prognosis. A new mechanism to explain subpial Sylvian hematoma formation in acute post-aneurysmal subarachnoid hemorrhage (SAH) was observed during coiling of a posterior communicating artery aneurysm. Multiple small bleeding points from pial branches of the left middle cerebral artery, which were remote from the ruptured aneurysm, were observed on conventional angiography. This bleeding led to the formation of a large expanding subpial Sylvian hematoma. Similar observations have been recently demonstrated on 4D CT angiography (4D CTA). We present a case that adds evidence to the literature in support of a new mechanism of subpial hematoma formation in the setting of acute SAH. This may advocate the early use of 4D CTA and conveys a poor prognosis, which might influence treatment decisions., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Subpial hematoma is a rare type of intracranial hemorrhage with a poor prognosis. A new mechanism to explain subpial Sylvian hematoma formation in acute post-aneurysmal subarachnoid hemorrhage (SAH) was observed during coiling of a posterior communicating artery aneurysm. Multiple small bleeding points from pial branches of the left middle cerebral artery, which were remote from the ruptured aneurysm, were observed on conventional angiography. This bleeding led to the formation of a large expanding subpial Sylvian hematoma. Similar observations have been recently demonstrated on 4D CT angiography (4D CTA). We present a case that adds evidence to the literature in support of a new mechanism of subpial hematoma formation in the setting of acute SAH. This may advocate the early use of 4D CTA and conveys a poor prognosis, which might influence treatment decisions., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

A 35-year-old man was found to have a cerebral abscess secondary to a recurrent sigmoid diverticular abscess. Both cultures grew Streptococcus anginosus. Brain abscess is a rare but potential complication of sigmoid diverticulitis. Streptococcus anginosus, which is found in human gut flora, is a common cause of brain abscess.

Objective: Tandem occlusions involving both the extracranial internal carotid artery (ICA) and an intracranial artery typically respond poorly to intravenous (IV) tissue plasminogen activator (t-PA). We retrospectively review our experience with proximal ICA stenting and stent-assisted thrombectomy of the distal artery., Methods: The data included patients that underwent carotid stenting and mechanical thrombectomy between 2012-2013. Radiographic, clinical, and procedural data were drawn from case notes, imaging records and discharge reports. Clinical outcomes were evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale (mRs)., Results: Seven patients, with a mean age of 66.4 years and a mean admission NIHSS of 18.3, underwent this procedure and were included. Each presented with an occlusion of the proximal ICA, with additional occlusions of the ICA terminus (n = 3), middle cerebral artery (n = 5), or anterior cerebral artery (n = 1). Recanalisation of all identified occlusions was achieved in all patients, with a Thrombolysis in Myocardial Infarction (TIMI) score of 3 and a Thrombolysis in Cerebral Infarction (TICI) score >2b achieved in each case. Mean time from onset of stroke symptoms to recanalisation was 287 min; mean time from first angiography to recanalisation was 52 min. Intracranial haemorrhages occurred in two patients, with no increase in NIHSS. There were no mortalities. Mean NIHSS at discharge was 4.9, and mRs at 90 days was one in all patients., Conclusions: Treatment of tandem extracranial ICA and intracranial occlusions in the setting of acute ischaemic stroke with extracranial carotid artery stenting followed by adjunctive intracranial mechanical thrombectomy is both safe and effective, but further evaluation of this treatment modality is necessary., (© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

A 44-year-old woman presented with recurrent episodes of thunderclap headache. Neurological examination and computed tomography brain imaging were unremarkable. Cerebrospinal fluid findings were consistent with subarachnoid hemorrhage. Computed tomography angiography of the circle of Willis showed multiple areas of segmental vasoconstriction. This finding was confirmed on cerebral catheter angiography, with segmental vasoconstriction involving bilateral internal carotid, posterior cerebral, and external carotid branches. No aneurysm or other vascular abnormality was identified. She received treatment with nimodipine. A selective serotonin reuptake inhibitor, started 4 weeks earlier, was discontinued. Follow-up angiography after 3 months demonstrated complete resolution of the segmental vasoconstriction, confirming the diagnosis of reversible cerebral vasoconstriction syndrome (RCVS). She remained headache free at follow-up. To our knowledge, external carotid artery branch involvement in RCVS has been described only in one previous occasion.

The role of neurointerventional treatment, including local thrombolysis, for intracranial venous thrombosis (ICVT) currently remains uncertain. We describe a case of postpartum ICVT involving the straight sinus, with rapid neurological deterioration and progressive thrombosis, despite anticoagulation. She underwent multimodality neurointerventional treatment involving attempted mechanical clot disruption, microcatheter suction, intrathrombus thrombolysis and microballoon disruption and clot retrieval. The patient achieved a full clinical recovery, with radiological evidence of recanalisation at follow-up.

Objective: The objective was to review the clinical aspects and therapeutic strategies in a series of aneurysmal vasculopathies seen in children 15 years or under., Methods: From our dedicated neurovascular databank of patients, we reviewed 59 consecutive children who had 75 separate lesions., Results: The children were divided into four age groups: below 2 years (22%), 2-5 years (24%), 6-10 years (24%) and 11-15 years (30%). Thirty-three children had dissecting aneurysms, 2 had chronic post-traumatic aneurysms, 8 had infectious aneurysms and 16 had saccular lesions. Twenty-seven percent of the lesions were in the posterior circulation, and 21% developed on the middle cerebral artery. Most dissecting lesions were encountered in the vertebrobasilar system, while saccular lesions were present mostly in the anterior circulation. Half of all cases presented with haemorrhage. Haemorrhage in patients below 2 years of age was due to dissecting aneurysms, while saccular aneurysms were responsible for haemorrhage in patients above 5 years of age. Five children had familial disease and 9 presented with multiple aneurysms. Forty-eight children were referred to us for treatment. Thirty-two underwent surgical (21.9%), endovascular (62.8%) or combined (9.3%) treatment. Eleven patients were treated conservatively and in 5 patients the aneurysms had spontaneously thrombosed at admission. Overall, complete or partial spontaneous thrombosis was seen in 10 patients (16.9%). Dissecting aneurysms were frequent in children of all ages with either associated thrombosis or arterial tear with repeated acute haemorrhage and poor outcome. Two types of dissection seem identifiable despite the small number of cases collected: acute segmental arterial tear without thrombosis, acute subarachnoid haemorrhage (SAH) and recurrence before 5 years; and subacute focal dissection with partial thrombosis (or mural haematoma), rare SAH and no early recurrence. The former would require aggressive management whereas the latter often do not require interventional approaches. The mortality in our series of aneurysms is low in the treated group (10.42%). The overall tolerance to haemorrhage seems better than in adults, as already stressed in the literature., Conclusion: The multiple etiologies encountered confirm the heterogenous nature of "aneurysms". The variety of treatments used suggests the need to categorise aneurysms into subgroups in sufficient numbers to fully appreciate the behavior of the lesions and make the appropriate therapeutic decisions.