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Cameron M. McDougall, Vin Shen Ban, Jeffrey Beecher, Lee Pride and Babu G. Welch

OBJECTIVE

The role of venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) is not well understood. The aim of this systematic review is to attempt to identify subsets of patients with IIH who will benefit from VSS based on the pressure gradients of their venous sinus stenosis.

METHODS

MEDLINE/PubMed was searched for studies reporting venous pressure gradients across the stenotic segment of the venous sinus, pre- and post-stent pressure gradients, and clinical outcomes after VSS. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

From 32 eligible studies, a total of 186 patients were included in the analysis. Patients who had favorable outcomes had higher mean pressure gradients (22.8 ± 11.5 mm Hg vs 17.4 ± 8.0 mm Hg, p = 0.033) and higher changes in pressure gradients after stent placement (19.4 ± 10.0 mm Hg vs 12.0 ± 6.0 mm Hg, p = 0.006) compared with those with unfavorable outcomes. The post-stent pressure gradients between the 2 groups were not significantly different (2.8 ± 4.0 mm Hg vs 2.7 ± 2.0 mm Hg, p = 0.934). In a multivariate stepwise logistic regression controlling for age, sex, body mass index, CSF opening pressure, pre-stent pressure gradient, and post-stent pressure gradient, the change in pressure gradient with stent placement was found to be an independent predictor of favorable outcome (p = 0.028). Using a pressure gradient of 21 as a cutoff, 81/86 (94.2%) of patients with a gradient > 21 achieved favorable outcomes, compared with 82/100 (82.0%) of patients with a gradient ≤ 21 (p = 0.022).

CONCLUSIONS

There appears to be a relationship between the pressure gradient of venous sinus stenosis and the success of VSS in IIH. A randomized controlled trial would help elucidate this relationship and potentially guide patient selection.

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Christopher L. Taylor, Kim Dutton, George Rappard, G. Lee Pride, Robert Replogle, Phillip D. Purdy, Jonathan White, Cole Giller, Thomas A. Kopitnik Jr. and Duke S. Samson

Object. Preoperative embolization is viewed by the authors as a useful adjunct in the surgical management of cerebral arteriovenous malformations (AVMs). This study was performed to determine the rate of significant complication in patients undergoing this procedure.

Methods. Demographic, anatomical, and procedure data were collected prospectively. The treating physician reported complications. In addition, a review of medical records including procedure reports, operative reports, and discharge summaries was performed. Univariate statistical analysis was performed to determine if any of the variables was predictive of a poor outcome of embolization (death or permanent neurological deficit).

Endovascular procedures for embolization were performed 339 times in 201 patients during an 11-year period. Female patients comprised 53.7% of the study group and 85.6% of the AVMs were supratentorial. Embolization was performed using polyvinyl alcohol particles, N-butyl cyanoacrylate, detachable coils, and/or the liquid polymer Onyx. Analyzed by procedure, a poor result of embolization occurred in 7.7%. Analyzed by patient, 11% died or had a permanent neurological deficit as a result of the embolization. None of the demographic, anatomical, or procedure variables identified were predictive of a poor outcome.

Conclusions. Preoperative embolization may gradually reduce flow to an AVM, reduce intraoperative blood loss, and reduce operative time. The risks of this procedure, however, are not insignificant and must be considered in planning treatment for patients with AVMs.

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J. Brett Fleming, Brian L. Hoh, Scott D. Simon, Babu G. Welch, Robert A. Mericle, Kyle M. Fargen, G. Lee Pride, Phillip D. Purdy, Chevis N. Shannon and Mark R. Harrigan

Object

Postprocedural rebleeding is a significant source of morbidity following endovascular treatment of ruptured intracranial aneurysms. Previous large-scale reports include the Cerebral Aneurysm Rerupture After Treatment trial, the International Subarachnoid Aneurysm Trial, and the study on Early Rebleeding after Coiling of Ruptured Cerebral Aneurysms, which reported nonprocedural rebleeding rates within 30 days of treatment of 2.7%, 1.9%, and 1.4%, respectively. However, coiling of intracranial aneurysms is in a state of continual change due to advancing device design and evolving techniques. These studies included only patients initially treated prior to 2004. In the present study the authors assess the most recent short-term results with endovascular treatment of ruptured aneurysms.

Methods

A multicenter retrospective chart review was conducted of patients undergoing endovascular treatment for ruptured intracranial aneurysms between July 2004 and October 2009. The technique used, including the use of stent or balloon assistance, was evaluated. Demographic and clinical factors, such as sex, age, initial clinical presentation, aneurysm size, aneurysm location, and modified Raymond Classification following initial treatment, were also evaluated and compared between the groups in which rebleeding did and did not occur.

Results

A total of 469 patients underwent endovascular treatment for a ruptured aneurysm; nonprocedural rehemorrhage occurred within 30 days of the initial coiling in 4 cases (0.9%). Two patients (50%) died after rehemorrhage. Stent-assisted coiling was used during the original treatment in 1 (25%) of the 4 patients with a rerupture. However, no technical, clinical, or demographic factors were found to be statistically significant in association with rebleeding.

Conclusions

Recent data suggest that the periprocedural rebleeding rate may be improving over time.