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Nohra Chalouhi, Nikolaos Mouchtouris, Fadi Al Saiegh, Somnath Das, Ahmad Sweid, Adam E. Flanders, Robert M. Starke, Michael P. Baldassari, Stavropoula Tjoumakaris, Michael Reid Gooch, Syed Omar Shah, David Hasan, Nabeel Herial, Robin D’Ambrosio, Robert Rosenwasser and Pascal Jabbour

OBJECTIVE

MRI and MRA studies are routinely obtained to identify the etiology of intracerebral hemorrhage (ICH). The diagnostic yield of MRI/MRA in the setting of an acute ICH, however, remains unclear. The authors’ goal was to determine the utility of early MRI/MRA in detecting underlying structural lesions in ICH and to identify patients in whom additional imaging during hospitalization could safely be foregone.

METHODS

The authors reviewed data obtained in 400 patients with spontaneous ICH diagnosed on noncontrast head CT scans who underwent MRI/MRA between 2015 and 2017 at their institution. MRI/MRA studies were reviewed to identify underlying lesions, such as arteriovenous malformations, aneurysms, cavernous malformations, arteriovenous fistulas, tumors, sinus thrombosis, moyamoya disease, and abscesses.

RESULTS

The median patient age was 65 ± 15.8 years. Hypertension was the most common (72%) comorbidity. Structural abnormalities were detected on MRI/MRA in 12.5% of patients. Structural lesions were seen in 5.7% of patients with basal ganglia/thalamic ICH, 14.1% of those with lobar ICH, 20.4% of those with cerebellar ICH, and 27.8% of those with brainstem ICH. Notably, the diagnostic yield of MRI/MRA was 0% in patients > 65 years with a basal ganglia/thalamic hemorrhage and 0% in those > 85 years with any ICH location, whereas it was 37% in patients < 50 years and 23% in those < 65 years. Multivariate analysis showed that decreasing age, absence of hypertension, and non–basal ganglia/thalamic location were predictors of finding an underlying lesion.

CONCLUSIONS

The yield of MRI/MRA in ICH is highly variable, depending on patient age and hemorrhage location. The findings of this study do not support obtaining early MRI/MRA studies in patients ≥ 65 years with basal ganglia/thalamic ICH or in any ICH patients ≥ 85 years. In all other situations, early MRI/MRA remains valuable in ruling out underlying lesions.

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Nikolaos Mouchtouris, Michael J. Lang, Kaitlyn Barkley, Guilherme Barros, Justin Turpin, Ahmad Sweid, Robert M. Starke, Nohra Chalouhi, Pascal Jabbour, Robert H. Rosenwasser and Stavropoula Tjoumakaris

OBJECTIVE

The authors sought to determine the predictors of late neurological and hospital-acquired medical complications (HACs) in patients with low-grade aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

The authors conducted a retrospective study of 424 patients with low-grade aSAH admitted to their institution from 2008 to 2015. Data collected included patient comorbidities, Hunt and Hess (HH) grade, ICU length of stay (LOS), and complications. A logistic regression analysis was performed to determine the predictors for neurological and hospital-associated complications.

RESULTS

Out of 424 patients, 50 (11.8%) developed neurological complications after the first week, with a mean ICU stay of 16.3 ± 6.5 days. Of the remaining 374 patients without late neurological complications, 83 (22.2%) developed late HACs with a mean LOS of 15.1 ± 7.6 days, while those without medical complications stayed 11.8 ± 6.2 days (p = 0.001). Of the 83 patients, 55 (66.3%) did not have any HACs in the first week. Smoking (p = 0.062), history of cardiac disease (p = 0.043), HH grade III (p = 0.012), intraventricular hemorrhage (IVH) (p = 0.012), external ventricular drain (EVD) placement (p = 0.002), and early pneumonia/urinary tract infection (UTI)/deep vein thrombosis (DVT) (p = 0.001) were independently associated with late HACs. Logistic regression showed early pneumonia/UTI/DVT (p = 0.026) and increased HH grade (p = 0.057) to be significant risk factors for late medical complications.

CONCLUSIONS

While an extended ICU admission allows closer monitoring, low-grade aSAH patients develop HACs despite being at low risk for neurological complications. The characteristics of low-grade aSAH patients who would benefit from early discharge are reported in detail.

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Mario Zanaty, Susanna Howard, Jorge A. Roa, Carlos M. Alvarez, David K. Kung, David J. McCarthy, Edgar A. Samaniego, Daichi Nakagawa, Robert M. Starke, Kaustubh Limaye, Sami Al Kasab, Nohra Chalouhi, Pascal Jabbour, James Torner, Daniel Tranel and David Hasan

OBJECTIVE

Revascularization of a symptomatic, medically refractory, cervical chronically occluded internal carotid artery (COICA) using endovascular techniques (ETs) has surfaced as a viable alternative to extracranial-intracranial bypass. The authors aimed to assess the safety, success, and neurocognitive outcomes of recanalization of COICA using ETs or hybrid treatment (ET plus carotid endarterectomy) and to identify candidate radiological markers that could predict success.

METHODS

The authors performed a retrospective analysis of their prospectively collected institutional database and used their previously published COICA classification to assess the potential benefits of ETs or hybrid surgery to revascularize symptomatic patients with COICA. Subjects who had undergone CT perfusion (CTP) imaging and Montreal Cognitive Assessment (MoCA) testing, both pre- and postprocedure, were included. The authors then performed a review of the literature on patients with COICA to further evaluate the success and safety of these treatment alternatives.

RESULTS

The single-center study revealed 28 subjects who had undergone revascularization of symptomatic COICA. Five subjects had CTP imaging and MoCA testing pre- and postrevascularization and thus were included in the study. All 5 patients had very large penumbra involving the entire hemisphere supplied by the ipsilateral COICA, which resolved postoperatively. Significant improvement in neurocognitive outcome was demonstrated by MoCA testing after treatment (preprocedure: 19.8 ± 2.4, postprocedure: 27 ± 1.6; p = 0.0038). Moreover, successful revascularization of COICA led to full restoration of cerebral hemodynamics in all cases. Review of the literature identified a total of 333 patients with COICA. Of these, 232 (70%) showed successful recanalization after ETs or hybrid surgery, with low major and minor complication rates (3.9% and 2.7%, respectively).

CONCLUSIONS

ETs and hybrid surgery are safe and effective alternatives to revascularize patients with symptomatic COICA. CTP imaging could be used as a radiological marker to assess cerebral hemodynamics and predict the success of revascularization. Improvement in CTP parameters is associated with significant improvement in neurocognitive functions.

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Robert M. Starke, David J. McCarthy, Ching-Jen Chen, Hideyuki Kano, Brendan J. McShane, John Lee, Mohana Rao Patibandla, David Mathieu, Lucas T. Vasas, Anthony M. Kaufmann, Wei Gang Wang, Inga S. Grills, Christopher P. Cifarelli, Gabriella Paisan, John Vargo, Tomas Chytka, Ladislava Janouskova, Caleb E. Feliciano, Nanthiya Sujijantarat, Charles Matouk, Veronica Chiang, Judith Hess, Rafael Rodriguez-Mercado, Daniel A. Tonetti, L. Dade Lunsford and Jason P. Sheehan

OBJECTIVE

The authors performed a study to evaluate the hemorrhagic rates of cerebral dural arteriovenous fistulas (dAVFs) and the risk factors of hemorrhage following Gamma Knife radiosurgery (GKRS).

METHODS

Data from a cohort of patients undergoing GKRS for cerebral dAVFs were compiled from the International Radiosurgery Research Foundation. The annual posttreatment hemorrhage rate was calculated as the number of hemorrhages divided by the patient-years at risk. Risk factors for dAVF hemorrhage prior to GKRS and during the latency period after radiosurgery were evaluated in a multivariate analysis.

RESULTS

A total of 147 patients with dAVFs were treated with GKRS. Thirty-six patients (24.5%) presented with hemorrhage. dAVFs that had any cortical venous drainage (CVD) (OR = 3.8, p = 0.003) or convexity or torcula location (OR = 3.3, p = 0.017) were more likely to present with hemorrhage in multivariate analysis. Half of the patients had prior treatment (49.7%). Post-GRKS hemorrhage occurred in 4 patients, with an overall annual risk of 0.84% during the latency period. The annual risks of post-GKRS hemorrhage for Borden type 2–3 dAVFs and Borden type 2–3 hemorrhagic dAVFs were 1.45% and 0.93%, respectively. No hemorrhage occurred after radiological confirmation of obliteration. Independent predictors of hemorrhage following GKRS included nonhemorrhagic neural deficit presentation (HR = 21.6, p = 0.027) and increasing number of past endovascular treatments (HR = 1.81, p = 0.036).

CONCLUSIONS

Patients have similar rates of hemorrhage before and after radiosurgery until obliteration is achieved. dAVFs that have any CVD or are located in the convexity or torcula were more likely to present with hemorrhage. Patients presenting with nonhemorrhagic neural deficits and a history of endovascular treatments had higher risks of post-GKRS hemorrhage.

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Robert M. Starke, David J. McCarthy, Ching-Jen Chen, Hideyuki Kano, Brendan McShane, John Lee, David Mathieu, Lucas T. Vasas, Anthony M. Kaufmann, Wei Gang Wang, Inga S. Grills, Mohana Rao Patibandla, Christopher P. Cifarelli, Gabriella Paisan, John A. Vargo, Tomas Chytka, Ladislava Janouskova, Caleb E. Feliciano, Rafael Rodriguez-Mercado, Daniel A. Tonetti, L. Dade Lunsford and Jason P. Sheehan

OBJECTIVE

In this multicenter study, the authors reviewed the results obtained in patients who underwent Gamma Knife radiosurgery (GKRS) for dural arteriovenous fistulas (dAVFs) and determined predictors of outcome.

METHODS

Data from a cohort of 114 patients who underwent GKRS for cerebral dAVFs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as dAVF obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and dAVF characteristics were assessed to determine predictors of outcome in a multivariate logistic regression analysis; dAVF-free obliteration was calculated in a competing-risk survival analysis; and Youden indices were used to determine optimal radiosurgical dose.

RESULTS

A mean margin dose of 21.8 Gy was delivered. The mean follow-up duration was 4 years (range 0.5–18 years). The overall obliteration rate was 68.4%. The postradiosurgery actuarial rates of obliteration at 3, 5, 7, and 10 years were 41.3%, 61.1%, 70.1%, and 82.0%, respectively. Post-GRKS hemorrhage occurred in 4 patients (annual risk of 0.9%). Radiation-induced imaging changes occurred in 10.4% of patients; 5.2% were symptomatic, and 3.5% had permanent deficits. Favorable outcome was achieved in 63.2% of patients. Patients with middle fossa and tentorial dAVFs (OR 2.4, p = 0.048) and those receiving a margin dose greater than 23 Gy (OR 2.6, p = 0.030) were less likely to achieve a favorable outcome. Commonly used grading scales (e.g., Borden and Cognard) were not predictive of outcome. Female sex (OR 1.7, p = 0.03), absent venous ectasia (OR 3.4, p < 0.001), and cavernous carotid location (OR 2.1, p = 0.019) were predictors of GKRS-induced dAVF obliteration.

CONCLUSIONS

GKRS for cerebral dAVFs achieved obliteration and avoided permanent complications in the majority of patients. Those with cavernous carotid location and no venous ectasia were more likely to have fistula obliteration following radiosurgery. Commonly used grading scales were not reliable predictors of outcome following radiosurgery.

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Allan D. Levi, Robert M. Starke, Ricardo J. Komotar and Robert E. Harbaugh

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I. Jonathan Pomeraniec, Dale Ding, Robert M. Starke, Kenneth C. Liu, E. Kelly Mrachek, M. Beatriz Lopes and Jason P. Sheehan

OBJECTIVE

Stereotactic radiosurgery (SRS) is a commonly employed treatment modality for brain arteriovenous malformations (AVMs). However, due to the low frequency of delayed cyst formation after AVM SRS, as well as the prolonged time interval between treatment and its occurrence, the characteristics of post-SRS cyst formation are not well defined. Therefore, the aims of this retrospective cohort study are to determine the rate of cyst formation after SRS for AVMs, identify predictive factors, and evaluate the clinical sequelae of post-SRS cysts.

METHODS

The authors analyzed an SRS database for AVM patients who underwent SRS at the University of Virginia and identified those who developed post-SRS cysts. Statistical analyses were performed to determine predictors of post-SRS cyst formation and the effect of cyst formation on new or worsening seizures after SRS.

RESULTS

The study cohort comprised 1159 AVM patients treated with SRS; cyst formation occurred in 17 patients (post-SRS cyst rate of 1.5%). Compared with patients who did not develop post-SRS cysts, those with cyst formation were treated with a greater number of radiosurgical isocenters (mean 3.8 vs 2.8, p = 0.047), had a longer follow-up (mean 132 vs 71 months, p < 0.001), were more likely to develop radiological radiation-induced changes (RIC) (64.7% vs 36.1%, p = 0.021), and had a longer duration of RIC (57 vs 21 months, p < 0.001). A higher number of isocenters (p = 0.014), radiological RIC (p = 0.002), and longer follow-up (p = 0.034) were found to be independent predictors of post-SRS cyst formation in the multivariate analysis. There was a trend toward a significant association between cyst formation and new or worsening seizures in univariate analysis (p = 0.054).

CONCLUSIONS

Patients with greater nidal complexity appear to be more prone to post-SRS cyst formation. The findings of this study emphasize the importance of long-term follow-up for patients who have undergone AVM SRS, even after nidal obliteration is achieved. Post-SRS cysts may be epileptogenic, although seizure outcomes after AVM SRS are multifactorial.

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Joseph S. Hudson, Yasunori Nagahama, Daichi Nakagawa, Robert M. Starke, Brian J. Dlouhy, James C. Torner, Pascal Jabbour, Lauren Allan, Colin P. Derdeyn, Jeremy D. W. Greenlee and David Hasan

OBJECTIVE

Intracranial stenting and flow diversion require the use of dual antiplatelet therapy (DAPT) to prevent in-stent thrombosis. DAPT may significantly increase the risk of hemorrhagic complications in patients who require subsequent surgical interventions. In this study, the authors sought to investigate whether DAPT is a risk factor for hemorrhagic complications associated with ventriculoperitoneal (VP) shunt placement in patients with aneurysmal subarachnoid hemorrhage (aSAH). Moreover, the authors sought to compare VP shunt complication rates with respect to the shunt’s location from the initial external ventricular drain (EVD) site.

METHODS

Patients with aSAH who presented to the authors’ institution from July 2009 through November 2016 and required VP shunt placement for persistent hydrocephalus were included. The rates of hemorrhagic complications associated with VP shunt placement were compared between patients who were on a regimen of DAPT (aspirin and clopidogrel) for use of a stent or flow diverter, and patients who underwent microsurgical clipping or coiling only and were not on DAPT using a backward stepwise multivariate analysis. Rates of radiographic hemorrhage and infection-related VP shunt revision were compared between patients who underwent VP shunt placement along the same track and those who underwent VP shunt placement at a different site (contralateral or posterior) from the initial EVD.

RESULTS

A total of 443 patients were admitted for the management of aSAH. Eighty of these patients eventually required VP shunt placement. Thirty-two patients (40%) had been treated with stent-assisted coiling or flow diverters and required DAPT, whereas 48 patients (60%) had been treated with coiling without stents or surgical clipping and were not on DAPT at the time of VP shunt placement. A total of 8 cases (10%) of new hemorrhage were observed along the intracranial proximal catheter of the VP shunt. Seven of these hemorrhages were observed in patients on DAPT, and 1 occurred in a patient not on DAPT. After multivariate analysis, only DAPT was significantly associated with hemorrhage (OR 31.23, 95% CI 2.98–327.32; p = 0.0001). One patient (3%) on DAPT who experienced hemorrhage required shunt revision for hemorrhage-associated proximal catheter blockage. The remaining 7 hemorrhages were clinically insignificant. The difference in rates of hemorrhage between shunt placement along the same track and placement at a different site of 0.07 was not significant (6/47 vs 2/32, p = 0.46). The difference in infection-related VP shunt revision rate was not significantly different (1/47 vs 3/32, p = 0.2978).

CONCLUSIONS

This clinical series confirms that, in patients with ruptured aneurysms who are candidates for stent-assisted coiling or flow diversion, the risk of clinically significant VP shunt–associated hemorrhage with DAPT is low. In an era of evolving endovascular therapeutics, stenting or flow diversion is a viable option in select aSAH patients.

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David Hasan, Mario Zanaty, Robert M. Starke, Elias Atallah, Nohra Chalouhi, Pascal Jabbour, Amit Singla, Waldo R. Guerrero, Daichi Nakagawa, Edgar A. Samaniego, Nnenna Mbabuike, Rabih G. Tawk, Adnan H. Siddiqui, Elad I. Levy, Roberta L. Novakovic, Jonathan White, Clemens M. Schirmer, Thomas G. Brott, Hussain Shallwani and L. Nelson Hopkins

OBJECTIVE

The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%–7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization.

METHODS

The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13%]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100% cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography.

RESULTS

Four types (A–D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2–6 months’ follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73).

CONCLUSIONS

The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.