Search

Background Symptomatic vertebral artery stenosis is associated with a high risk of recurrent stroke, with higher risks for intracranial than for extracranial stenosis. Vertebral artery stenosis can be treated with stenting with good technical results, but whether it results in improved clinical outcome is uncertain. We aimed to compare vertebral stenting with medical treatment for symptomatic vertebral stenosis. Methods We did a preplanned pooled individual patient data analysis of three completed randomised controlled trials comparing stenting with medical treatment in patients with symptomatic vertebral stenosis. The primary outcome was any fatal or non-fatal stroke. Analyses were performed for vertebral stenosis at any location and separately for extracranial and intracranial stenoses. Data from the intention-to-treat analysis were used for all studies. We estimated hazard ratios (HRs) with 95% CIs using Cox proportional-hazards regression models stratified by trial. Findings Data were from 354 individuals from three trials, including 179 patients from VIST (148 with extracranial stenosis and 31 with intracranial stenosis), 115 patients from VAST (96 with extracranial stenosis and 19 with intracranial stenosis), and 60 patients with intracranial stenosis from SAMMPRIS (no patients had extracranial stenosis). Across all trials, 168 participants (46 with intracranial stenosis and 122 with extracranial stenosis) were randomly assigned to medical treatment and 186 to stenting (64 with intracranial stenosis and 122 with extracranial stenosis). In the stenting group, the frequency of periprocedural stroke or death was higher for intracranial stenosis than for extracranial stenosis (ten (16%) of 64 patientsvsone (1%) of 121 patients; pinteraction=0·395). Interpretation Stenting for vertebral stenosis has a much higher risk for intracranial, compared with extracranial, stenosis. This pooled analysis did not show evidence of a benefit for stroke prevention for either treatment. There was no evidence of benefit of stenting for intracranial stenosis. Stenting for extracranial stenosis might be beneficial, but further larger trials are required to determine the treatment effect in this subgroup. Funding None.

A 70-year-old woman reported recurrent episodes of right- or left-sided sensorimotor disturbance, thought to be recurrent transient ischaemic attacks. The episodes continued despite treatment with antiplatelet agents. When MRI revealed microhaemorrhages and focal superficial cortical haemosiderin deposition, antiplatelet agents were discontinued and her transient focal neurological episodes stopped. The imaging appearances suggested cerebral amyloid angiopathy (CAA) associated with superficial siderosis—although fulfilling criteria only for ‘possible CAA’. The case highlights the diversity of transient focal neurological episodes and the difficulties in current terminology and understanding of the clinical manifestations of CAA. A 70-year-old woman presented in 2007 with episodes of left- or right-sided paraesthesiae, which would gradually spread over the affected side, sometimes associated with difficulty in walking, or episodes of expressive dysphasia with sensory disturbance in the mouth or tongue. The attacks typically evolved over several minutes and lasted up to 30 min. They occurred up to three times a week over an 18-month period. She had no significant medical history, nor any relevant family history. Her general practitioner had started aspirin after the first episode in August 2007; dipyridamole had subsequently been added at the local transient ischaemic attack (TIA) clinic. However, the events became more frequent and severe. She scored 95/100 on the Addenbrookes Cognitive Examination-Revised (ACE-R). Carotid Doppler ultrasound studies found no significant extracranial precerebral arterial stenoses. Interictal EEGs demonstrated bitemporal epileptiform changes, with frequent irregular slow wave activity with sharp components in the middle to anterior temporal region bilaterally. In early 2009, an MR brain scan showed a small (1.3 cm) intraparenchymal haemorrhage in the right parietal lobe. Further MRI with gradient …

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.

Generating Pareto surfaces is a well accepted technique in multiattribute decision making. Alternatively, an interactive approach may be used where designs on the Pareto frontier are compared or rank ordered and newer designs are generated to maximize an implicit utility function. When each function evaluation involves a finite element analysis or other type of simulation, multicriteria approaches can become highly computationally expensive. In this context, techniques for reducing computing time using parallel processors are discussed. A structural topology problem is chosen as a test problem and Pareto surfaces are generated using two different clusters. Near linear speed-ups and high efficiencies are observed on both the clusters. It is possible to integrate this methodology into computer programs that assist design engineers in the industry leading so that less turn around time is required to make critical decisions.

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.

A 62-year-old lady presented to hospital with thunderclap headache and was found to have a grade 1 subarachnoid haemorrhage due to ruptured anterior communicating artery (ACoA) aneurysm, treated by endovascular coiling. Two small coincidental left middle cerebral artery (MCA) aneurysms were managed conservatively. Follow-up imaging at 6 months showed only minor ischaemic changes. Routine 2 year follow up magnetic resonance angiography (MRA) showed the coiled aneurysm to be secure with unchanged coincidental MCA aneurysms but multiple new right cerebral hemisphere lesions with extensive perilesional oedema. These lesions showed punctate enhancement on contrast MRI. 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) imaging showed normal brain FDG update. The patient developed focal left-sided motor seizures, prompting readmission, and empirical treatment with corticosteroids, antibiotics and aspirin in addition to levetiracetam. Cerebral spinal fluid constituents were normal. Routine bloods, inflammatory markers and blood cultures were normal or negative, as was an echocardiogram. There were no further seizures, and subsequent improvement was noted in the right cerebral hemisphere imaging appearances. Foreign material emboli following endovascular coiling is described in the literature but, to our knowledge, its presentation in this manner with this latency has not been reported.

Generating Pareto surfaces is a well-accepted technique in multi-attribute decision making. For computationally intensive applications like finite element based optimization, it can become very expensive to generate the complete Pareto surface. Hence, using parallel computer clusters in these scenarios becomes very attractive. Pareto surfaces are generated using two different clusters with a structural topology problem as a test problem and the performance gains realized are analyzed. Near linear speed-ups and high efficiencies are observed on both the clusters. It is possible to integrate this methodology into commercial software applications, leading to less turn around times to make critical decisions in various applications.

White matter lesions (WML) on T2-weighted magnetic resonance imaging (MRI), particularly when extensive, are a marker of cerebral small-vessel disease (SVD). Anecdotally, WMLs were noted in follow-up imaging of patients with symptomatic cerebral aneurysms, but the underlying reason for this is unknown. In this study we investigated WMLs in patients with cerebral aneurysms. Consecutive patients were identified who underwent endovascular coiling of cerebral aneurysms at the Royal Preston Hospital between 2008 and 2010, for whom follow-up MRI scans were available. Scans from patients showing WMLs were anonymised and the lesion burden was estimated using the Fazekas visual rating score and by software-aided volumetric analysis. Comparison was made with an age-stratified outpatient control group who underwent brain MRI for headache. 157 patients had follow-up MRI scans. WMLs were reported in 38.2%, and 48% were scored Fazekas grade 2 or higher. The prevalence of WMLs in cases was significantly greater than that in age-stratified controls in patients aged 60–69y (p

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.