Search

Objective: This 2-year observational study aimed to test the feasibility of implementing a pediatric stroke triage-setup that connected frontline providers with vascular neurologists and to examine final diagnoses in children triaged for suspected stroke.Methods: Prospective, consecutive registration of children with suspected stroke triaged by a team of vascular neurologists from Jan 1st, 2020 and through Dec 2021, Eastern Denmark (census 530,000 children). Based on the provided clinical information, the children were triaged to either assessment at the Comprehensive Stroke Center (CSC) in Copenhagen or to a pediatric department. All included children were retrospectively followed-up for clinical presentations and final diagnosis.Results: A total of 163 children with 166 suspected stroke events were triaged by the vascular neurologists. Cerebrovascular disease was present in 15 (9.0%) suspected stroke events; one child had intracerebral hemorrhage, one had subarachnoid hemorrhage, two children presented with three TIA events and nine children presented with 10 ischemic stroke events. Two children with ischemic stroke were eligible for acute revascularization treatment of which both were triaged to the CSC. The sensitivity of the triage by acute revascularization indication was 1.00 (95% confidence interval (95% CI): 0.15–1.00) and specificity 0.65 (95% CI: 0.57–0.73). Non-stroke neurological emergencies were present in 34 (20.5%) children, including seizures in 18 (10.8%) and acute demyelinating disorders in 7 (4.2%).Conclusion: Implementing regional triage-setup that connected frontline providers to vascular neurologists was feasible; this system was activated for the majority of children with ischemic stroke according to an expected incidence and led to identification of children eligible for revascularization treatments.

Hypoglossal canal dural arteriovenous fistulas (HC-DAVF) involve the anterior condylar vein (ACV) and anterior condylar confluence (ACC). They often present with tinnitus, bruit, and hypoglossal nerve palsy. The most common treatment in HC-DAVFs is transvenous embolization using coils and the most direct transvenous route is the trans-internal jugular vein access. When this approach is not feasible, a treatment attempt is possible through alternative routes. We report 2 patients with DAVFs involving the anterior condylar confluence. The first patient presented with pulsatile tinnitus and hypoglossal nerve palsy, and was treated by a standard transjugular approach. The second patient presented with pulse-synchronous bruit. Following an unsuccessful attempt of the transjugular approach, the fistulous point was reached via the deep cervical vein and complete occlusion was achieved by coil deployment. Both patients had complete regression of symptoms. Endovascular therapy is the elective treatment for HC-DAVFs and the transjugular approach is the most commonly used. The deep cervical vein (DCV) can be an alternative transvenous route when the transjugular approach fails.

BackgroundWide necked bifurcation aneurysms (WNBA) are among the most difficult aneurysms to treat. Very low dome-to-neck (DTN) and aspect ratios provide an even greater challenge in the management of WNBAs. We present the safety and efficacy profile for endovascular clip system (eCLIPs) device in the treatment of this subset of WNBAs with very unfavorable morphologies.MethodsIn our case series, 24 patients treated at 12 international centers were taken from a larger prospective voluntary post-marketing registry of 65 patients treated with the eCLIPs device and coiling. Those who had WNBAs at either the carotid or basilar terminus with a DTN ratio <1.6 and aspect ratio <1.2 were included. Radiologic and clinical outcomes were assessed immediately after the procedure and at the latest follow-up.ResultsThe eCLIPs device was successfully deployed in 23 cases (96%). One patient (4.2%) died due to guidewire perforation distal to the implant site. No other complications were documented. After a mean follow-up of 15.8 months (range 3–40 months), good radiologic outcomes (modified Raymond–Roy classification (MRRC) scores of 1 or 2) were documented in 20 of 21 patients (95%) with follow-up data. The lone patient with an MRRC score of 3 showed coiled compaction after incomplete neck coverage with the device.ConclusionOur series of patients with aneurysms having adverse DTN and aspect ratios demonstrated that the eCLIPs device has a safety and efficacy profile comparable with currently available devices in the treatment of WNBAs.

Background Radiographic visualization of liquid embolic agents (LEAs) during embolization procedures in neurovascular territory represents a crucial feature to ensure efficacy and safety for the patients during endovascular treatment of arteriovenous shunting lesions. Radiopacity of available LEAs varies significantly and limited methods are currently available for comparison. The purpose of this study was to compare the contrast resolution (CR) during injection under blank roadmap of various LEAs, as well as standard contrast material.Methods An injectable angiographic phantom was designed consisting of parallel tubings between 313 and 1000 micron. Under roadmap, eight radiopaque liquid agents were injected and analyzed: Onyx18®, 34®Squid®12, 18, PHIL®25% (PHIL®25), PHIL®30% (PHIL®30). TrufillTM(NBCA), 30% dilution and Omnipaque®300. CR was evaluated as a contrast to noise ratio (CNR) and calculated as mean peak signal (Sa) minus mean background signal (Sb) divided by the standard deviation of the background signal (Std) (CNR=Sa−SbStd).Results Omnipaque 300 and NBCA were found to have the highest CR. PHIL®25 demonstrated the lowest CNR (45% of Omnipaque CNR). Onyx 18 and 34 (Both around 82% of Omnipaque CNR) demonstrated higher CNR compared to Squid®12 and 18 (52–55% of Omnipaque CNR). On average, at 500 micron there is a >70% reduction in CNR, and at 313 micron there is a 90% reduction in CNR compared to 1000 micron.Conclusions Significantly different CNR between most LEAs and iodinated contrast media was evident under roadmap conditions and should be considered prior to injection.

We report the case of a 29-year-old woman presenting with severe back pain and S1-radiculopathy. Digital subtraction angiography revealed a spinal cord arteriovenous malformation complicated by acute feeder dissection and pseudoaneurysm (PA) formation causing mass effect. After conservative management with limited angiographic and clinical improvement, selective treatment of the PA by flow diversion (FD) led to occlusion and shrinkage with the resolution of clinical symptoms. FD may be a feasible treatment option for spinal artery aneurysms in selected patients with favorable anatomy. The need for antiplatelet therapy is a limitation of its use with currently available devices.

This study reports the differences in evolution and course of multiple pseudoaneurysms (PAs) and an axillary arteriovenous fistula (AVF) after penetrating vascular trauma due to shotgun injury to the head and neck.We describe the unusual case of a young man who, following penetrating shotgun injuries to the head and neck, developed multiple PAs of the common carotid, vertebral and superficial temporal arteries as well as an axillary AVF. Serial angiographic follow-up studies documented differences in time of occurrence, evolution and course of these lesions. This allowed for tailored management using endovascular (AVF, superficial temporal artery PAs) and conservative (carotid and vertebral PAs) treatment. No complication occurred and complete cure of all lesions was achieved and documented after seven months.Time of occurrence, evolution and regression of penetrating vascular injuries can differ significantly even in the same patient. Close angiographic follow-up helps not only detect a lesion with delayed occurrence, but also provides a practical basis for decision-making for optimal therapeutic management.

Purpose: To report the increased efficacy of oversized, overlapping stents to treat an internal carotid artery (ICA) dissecting aneurysm.Case Report: A 55-year-old woman presented with reduced consciousness, aphasia, and right-sided hemiplegia owing to an infarction of the left middle cerebral artery territory documented by computed tomography. Digital subtraction angiography disclosed an extracranial dissection of the left ICA with a pseudoaneurysm. Two self-expanding Wallstents were placed, bridging the dissected segment and overlapping at the level of the aneurysm neck. Immediate arteriography showed remarkably reduced filling of the pseudoaneurysm. Serial arteriograms performed 6 days and 9 and 20 months after stenting documented the disappearance of the pseudoaneurysm without appreciable intimal hyperplasia of the vessel wall.Conclusions: Reducing stent porosity by overlapping the devices causes significant hemodynamic changes inside the aneurysm sac, accelerating intra-aneurysmal thrombosis.

Cerebral polymer coating embolism from intravascular devices represents a potentially serious complication to endovascular therapy (EVT). We report two cases of neuroendovascular treatment where filamentous polymer fragments were noted possibly due to damage of the surface coating during manipulation and backloading of microguidewires. As the exact origin of the debris was initially not known, microguidewires and fragments were examined with light microscopy, stereomicroscopy, scanning electron microscopy and attenuated-total-reflection Fourier transform infrared spectroscopy. Fragments consisted of polytetrafluoroethylene and silicone oil stemming from the proximal shaft of a standard microguidewire. To our knowledge, this is the first report of polytetrafluoroethylene coating fragments created during EVT. Future studies should assess the mechanism of polymer coating delamination and its potential consequences during EVT including inadvertent fragment migration into the cerebral circulation.

Purpose: To report the endovascular treatment of a spontaneous scalp arteriovenous fistula (AVF) in a child with Hartnup disease.Case Report: A 6-year-old girl with Hartnup disease presented with recurrent attacks of intense, migraine-like, right-sided headache; a tender, pulsatile small mass was observed in the scalp. Selective digital subtraction angiography revealed a high-flow scalp AVF fed by the frontal branch of the right superficial temporal artery draining via the scalp veins. Endovascular treatment was performed by direct puncture of the distal feeding artery and injection of 2 mL of a 50% mixture of N-butyl-cyanoacrylate and Lipiodol. Serial arteriograms performed 6 months and 2 years later documented complete resolution of the lesion. The patient has had no recurrence of clinical symptoms or local signs for recanalization.Conclusions: Scalp AVFs may progress in size, causing significantly disabling symptoms, particularly in children. We recommend endovascular treatment at the earliest possible stage.