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Nnenna Mbabuike, Kelly Gassie, Benjamin Brown, David A. Miller, and Rabih G. Tawk

OBJECTIVE

Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines.

METHODS

The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases.

RESULTS

A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively.

CONCLUSIONS

In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.

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William D. Freeman, Jason Sebesto, and Rabih G. Tawk

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Leonardo B. C. Brasiliense, Ramon Navarro, Paul Brazis, and Rabih G. Tawk

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Rabih G. Tawk, Mary Duffy-Fronckowiak, Bryan E. Scott, Ronald A. Alberico, Aidnag Z. Diaz, Matthew B. Podgorsak, Robert J. Plunkett, and Robert A. Fenstermaker

Object. The purpose of this study was to assess the durability and completeness of pain relief in patients treated using stereotactic gamma knife surgery (GKS) for trigeminal neuralgia (TN).

Methods. Thirty-eight patients with refractory TN were treated with stereotactic GKS. All patients received a prescription radiation dose of 35, 40, or 45 Gy to the 50% isodose surface through a 4-mm collimator helmet. The group was assessed regularly based on physician-directed interviews for a median follow up of 24 months (range 6–27 months). Pain relief was classified as excellent (no pain without medication), good (well-controlled pain with continued medication), fair (decreased but residual pain with continued medication), or poor (unimproved or increased pain with the same or increased medication).

Three months after treatment, pain relief was good or excellent in 71% of patients. By 24 months post-GKS, 50% of the original cohort had poor pain relief, 21% continued to have either excellent or good relief, 3% had fair relief, and 26% had not reached the 24-month follow up. Based on their status at the last follow up, 29% of patients had excellent and 16% had good pain relief. Thirty-seven percent experienced facial numbness, which was dose related. In addition, there was a significantly higher rate of complete pain relief in patients who had facial numbness following treatment (p = 0.003).

Conclusions. Stereotactic GKS is an effective treatment in patients with TN; however, the durability of pain relief and the time to treatment response are limiting factors. As with other types of ablative treatment, facial numbness is strongly associated with better treatment response.

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Ruth S. Kuo, Wililiam D. Freeman, and Rabih G. Tawk

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Neil Haranhalli, Nnenna Mbabuike, Sanjeet S. Grewal, Tasneem F. Hasan, Michael G. Heckman, William D. Freeman, Vivek Gupta, Prasanna Vibhute, Benjamin L. Brown, David A. Miller, Babak S. Jahromi, and Rabih G. Tawk

OBJECTIVE

The role of CT perfusion (CTP) in the management of patients with acute ischemic stroke (AIS) remains a matter of debate. The primary aim of this study was to evaluate the correlation between the areas of infarction and penumbra on CTP scans and functional outcome in patients with AIS.

METHODS

This was a retrospective review of 100 consecutively treated patients with acute anterior circulation ischemic stroke who underwent CT angiography (CTA) and CTP at admission between February 2011 and October 2014. On CTP, the volume of ischemic core and penumbra was measured using the Alberta Stroke Program Early CT Score (ASPECTS). CTA findings were also noted, including the site of occlusion and regional leptomeningeal collateral (rLMC) score. Functional outcome was defined by modified Rankin Scale (mRS) score obtained at discharge. Associations of CTP and CTA parameters with mRS scores at discharge were assessed using multivariable proportional odds logistic regression models.

RESULTS

The median age was 67 years (range 19–95 years), and the median NIH Stroke Scale score was 16 (range 2–35). In a multivariable analysis adjusting for potential confounding variables, having an infarct on CTP scans in the following regions was associated with a worse mRS score at discharge: insula ribbon (p = 0.043), perisylvian fissure (p < 0.001), motor strip (p = 0.007), M2 (p < 0.001), and M5 (p = 0.023). A worse mRS score at discharge was more common in patients with a greater volume of infarct core (p = 0.024) and less common in patients with a greater rLMC score (p = 0.004).

CONCLUSIONS

The results of this study provide evidence that several CTP parameters are independent predictors of functional outcome in patients with AIS and have potential to identify those patients most likely to benefit from reperfusion therapy in the treatment of AIS.

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Peter Kan, Visish M. Srinivasan, Nnenna Mbabuike, Rabih G. Tawk, Vin Shen Ban, Babu G. Welch, Maxim Mokin, Bartley D. Mitchell, Ajit Puri, Mandy J. Binning, and Edward Duckworth

The Pipeline Embolization Device (PED) was approved for the treatment of intracranial aneurysms from the petrous to the superior hypophyseal segment of the internal carotid artery. However, since its approval, its use for treatment of intracranial aneurysms in other locations and non-sidewall aneurysms has grown tremendously. The authors report on a cohort of 15 patients with 16 cerebral aneurysms that incorporated an end vessel with no significant distal collaterals, which were treated with the PED. The cohort includes 7 posterior communicating artery aneurysms, 5 ophthalmic artery aneurysms, 1 superior cerebellar artery aneurysm, 1 anterior inferior cerebellar artery aneurysm, and 2 middle cerebral artery aneurysms. None of the aneurysms achieved significant occlusion at the last follow-up evaluation (mean 24 months). Based on these observations, the authors do not recommend the use of flow diverters for the treatment of this subset of cerebral aneurysms.

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J Mocco, Rabih G. Tawk, Babak S. Jahromi, Rodney M. Samuelson, Adnan H. Siddiqui, L. Nelson Hopkins, and Elad I. Levy

Object

Endovascular treatment of acute thromboembolic stroke is a rapidly developing field that appears to hold great promise. Young patients may be particularly suited to benefit from endovascular acute stroke therapy. The authors sought to identify outcomes in young patients with thromboembolic stroke who underwent endovascular intervention.

Methods

The authors retrospectively reviewed a prospectively collected endovascular intervention registry of patients with ischemic strokes treated at a single large-volume institution between December 2000 and June 2007 to identify patients 18–35 years of age who were treated for thromboembolic stroke. Data are presented as the mean ± standard deviation unless otherwise noted.

Results

Seven young patients underwent 8 consecutive endovascular interventions for thromboembolic stroke (mean age 26 ± 6 years; 5 women). The National Institutes of Health Stroke Scale score at presentation was 13 ± 4.3 (median 13). All patients presented within 6 hours of symptom onset. Revascularization was attempted with mechanical thrombectomy/disruption, intraarterial thrombolysis, and/or angioplasty, with or without stent placement.

The modified Rankin Scale (mRS) score at discharge was 2.2 ± 1.5 (median 1.5), with 5 patients (62.5%) achieving independence at discharge (mRS Score 0–2). There were no deaths. Hospital length of stay was 6.5 ± 3.7 days (4.4 ± 1.5 days for patients with an mRS score of 0–2; 10 ± 3.6 days for patients with an mRS score of 4). All patients became independent and had reached an mRS score of ≤ 2 at last follow-up evaluation (29 ± 25 months).

Conclusions

The data demonstrate the relative safety of endovascular intervention in young patients with thromboembolic cerebral ischemia and may suggest a potential benefit in outcome. Further investigation is indicated with larger numbers of patients and an appropriate control population.

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Ricardo A. Domingo, Gaetano De Biase, Ramon Navarro, Jaime L. Martinez Santos, Gabriella A. Rivas, Vivek Gupta, David Miller, Bernard R. Bendok, Waleed Brinjikji, W. Christopher Fox, Thien J. Huynh, and Rabih G. Tawk

OBJECTIVE

Available data on management of sacral arteriovenous fistulas (sAVFs) are limited to individual case reports and small series. Management includes observation, endovascular embolization, or surgical ligation, with no clear guidelines on the optimal treatment modality. The authors’ objective was to report their multiinstitutional experience with management of sAVF patients, including clinical and radiographic characteristics and postprocedural outcomes.

METHODS

The electronic medical records of patients with a diagnosis of spinal arteriovenous fistula treated from January 2004 to December 2019 at the authors’ institutions were reviewed, and data were summarized using descriptive statistics, including percentage and count for categorical data, median as a measure of central tendency for continuous variables, and interquartile range (IQR) as a measure of dispersion.

RESULTS

A total of 26 patients with sAVFs were included. The median (IQR) age was 65 (57–73) years, and 73% (n = 19) of patients were male. Lower-extremity weakness was the most common presenting symptom (n = 24 [92%]), and half the patients (n = 13 [50%]) reported bowel and bladder sphincter dysfunction. The median (IQR) time from symptom onset to treatment was 12 (5.25–26.25) months. Radiographically, all patients had T2 hyperintensity at the level of the conus medullaris (CM) (n = 26 [100%]). Intradural flow voids were identified in 85% (n = 22) of patients. The majority of the lesions had a single identifiable arterial feeder (n = 19 [73%]). The fistula was located most commonly at the S1 level (n = 13 [50%]). The site where the draining vein connects to the pial venous plexus was seen predominantly at the lumbar level (n = 16 [62%]). In total, 29 procedures were performed: 10 open surgeries and 19 endovascular embolization procedures. Complete occlusion was achieved in 90% (n = 9) of patients after open surgery and 79% (n = 15) after endovascular embolization. Motor improvement was seen in 68% of patients (n = 15), and bladder and bowel function improved in 9 patients (41%). At last follow-up, 73% (n = 16) of patients had either resolution or improvement of the pretreatment intramedullary T2 signal hyperintensity.

CONCLUSIONS

T2 hyperintensity of the CM and a dilated filum terminale vein are consistent radiographic signs of sAVF, and delayed presentation is common. Complete occlusion was achieved in almost all patients after surgery, and endovascular embolization was effective in 70% of the patients. Further studies are needed to determine the best treatment modality based on case-specific characteristics.

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Ramon Navarro, Linaloe Kala, W. David Freeman, Ricardo A. Hanel, and Rabih G. Tawk