Background Mechanical thrombectomy (MT) is the gold standard treatment for large vessel occlusion (LVO). A vital factor that might influence MT outcomes is the use of intravenous thrombolysis (IVT). A few clinical trials in this domain thus far have not yielded consistent outcomes. We conducted this meta-analysis to synthesize collective evidence in this regard. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines were followed, and we performed a comprehensive literature search of four databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL). For outcomes constituting continuous data, the mean difference (MD) and its standard deviation (SD) were pooled. For outcomes constituting dichotomous data, the frequency of events and the total number of patients were pooled as the risk ratio (RR). Results Seven clinical trials with a total of 2317 patients are included in this meta-analysis. Six trials are randomized, and one trial was nonrandomized. No significant differences were found between MT plus IVT and MT alone in successful recanalization (RR 1.04, 95% Confidence Interval (CI) [0.92 to 1.17], P = 0.53), 90-day functional independence (RR 1.03, 95% CI [0.90 to 1.19], P = 0.65), symptomatic intracranial hemorrhage (sICH) (RR 1.22, 95% CI [0.84 to 1.75], P = 0.30), or mortality (RR 0.94, 95% CI [0.76 to 1.18], P = 0.61). Conclusion The current evidence does not favor either MT plus IVT or MT alone for LVO except for the procedural time. More trials are needed in this regard, and certain factors should be considered when comparing the two approaches.
IntroductionUnderstanding the potential embolic source in young patients with ESUS may improve the diagnosis and treatment of such patients.HypothesisPotential embolic sources (PES) differ in young vs. older patients with ESUS, and, therefore, not all patients with ESUS have the same risk profile for stroke recurrence.MethodsYoung patients (age 18-49) with ESUS, who were admitted to our stroke center from 2006 to 2019, were identified retrospectively and matched with next consecutive older patients (age 50–99) with ESUS by admission date. PES were categorized as atrial cardiopathy, AFib diagnosed during follow-up, left ventricular disease (LVD), cardiac valvular disease (CVD), PFO or atrial septal aneurysm (ASA), and arterial disease. Patients, who had cancer or thrombophilia, were excluded. The type and number of PES and stroke recurrence rates were determined and compared between young and older patients.ResultsIn young patients (55.3% women, median age 39 years), the most common PES was PFO/ASA, and the rate of other PES was low (2–7%). Half of the young patients (54.1%) had a single PES, only 10% had multiple PES, and 35.3% of young patients did not have any PES identified. In older patients (41.7% women, median age 74 years), the 3 most common PES were atrial cardiopathy (38.1%), LVD (35.7%), and arterial disease (23.8%). Nearly half of older patients (42.9%) had multiple PES. The rate of stroke recurrence tended to be lower in young patients as compared to older patients (4.9 vs. 11.4%, p = 0.29). During a median follow-up of 3 years, only 3 young patients (4.9%) had a recurrent stroke, and two of them had unclosed PFO. There were no recurrent strokes among young patients with no PES identified.ConclusionsIt was noted that PES differ in patients with ESUS according to age and differences in recurrence. PFO is the only common PES in young patients with ESUS. Future studies prospectively evaluating PES in both age groups are needed.
increase in size measuring 1.7 mm. At this point, with multideciplinary team approach, we decided to consider securing the aneurysm with endovascular approach. Patient also had functional MRI and tractography to complete open surgical planning evaluation if endovascular approach was unsuccessful. Meanwhile pateint's neurological deficits were completely resolved at approximately two month mark. Selective microcatheter angiographic runs on the day of treatment showed that the aneurysm had side wall morphology (2.3mm) with parent perforator blood vessel having significant basal ganglia territory supply. Considering inevitable sacrifice of the perforator while using endovascular approach, we proceeded with open surgical clipping of the aneurysm. The aneurysm was secured with surgical clipping preserving the parent perforator vessel.Distal lenticulostriate aneurysms are uncommon pathology. Considering very high risk of neurologic deficits with either endovascular or open surgical approach, these lesions need meticulous multidisciplinary team planning.
Introduction : Chronic subdural hematoma (cSDH) is a common neurosurgical condition with a high recurrence rate. Middle meningeal artery (MMA) embolization has been shown to reduce the incidence of re‐bleeding and prevent recurrence of cSDH by devascularizing the subdural membranes and shifting the balance from continued leakage and accumulation of blood and proteinaceous material to reabsorption. We report our single center experience of MMA embolization for treatment of chronic and subacute subdural hematoma. Methods : We performed a retrospective chart review of all patients ≥18 years who underwent MMA embolization between 01/01/2020‐03/01/2021 for cSDH. We looked at the outcomes, rate of recurrence and possible complications after MMA embolization. A descriptive analysis for continuous and categorical variables was performed using SAS 9.4 version. Results : A total of 41 MMA embolizations were performed on 32 patients with a median age of 75 (Q1‐Q3 70–83). Median hematoma thickness was 12 mm. Among them, 52% patients underwent particle embolization while 48% underwent liquid embolization. One patient had recurrence on follow up imaging and required drainage with burr hole. Three patients underwent hematoma evacuation after MMA embolization without evidence of recurrence on imaging. Three cases were aborted due to high risk or difficult access. There were no procedure related complications in the whole study population. 65% patient achieved mRS 0–2 on 90 day follow up visit. There was no significant difference between particles and liquid embolizations. Conclusions : Middle meningeal artery embolization could be used as a safe and effective intervention for prevention of recurrence and improving outcomes of subacute or chronic subdural hematoma.
Introduction Arteriovenous malformations (AVM) of the head and neck are vascular malformations composed of a cluster of connecting arteries and veins that form a central nidus without an intervening capillary network1. They make up 1.5% of vascular malformations and more than 90% of AVMs are located intracranially1. Extracranial AVMs are predominantly located in the head and neck and can manifest with pain, ulcerations, fatal hemorrhage, airway compromise, and cosmetic aberrations1,2. Methods We present a case of a 21 year old female with a medical history of multiple suspected neck hemangiomas status post microsurgical and laser resections, with a surrounding port wine stain, who presented to the hospital with growth of one of her posterior neck hemangiomas during and after pregnancy. In the postpartum period she reported increasing neck pain and persistent bleeding from the site. Initially, she was hemodynamically stable and her neurologic exam did not show any focal deficits. She underwent computed tomography angiogram of her neck which showed an extensive dorsal neck AVM with multiple arterial supplies frombranches of the bilateral subclavian, vertebral, and external carotid arteries.Her lesion continued to bleed with a precipitous drop in hemoglobin requiring blood transfusions. Subsequently, she underwent urgentpercutaneousN‐butyl‐2‐cyanoacrylate (n‐BCA) embolizationand endovascular onyx embolization of a left thyrocervical trunk branch.The procedure was completed without complications. Months later, she developed skin exfoliation and underwent successful elective embolization involving vertebral artery branches. This, to reduce profuse venous shunting in the paravertebral venous plexus, avoiding long term spinal cord injury. Results The management of complex head and neck AVMs is both challenging and complex. They may pose significant bleeding risk and can become infiltrative within surrounding tissue3. AVMs may be classified as either focal or diffuse. Focal lesions may be curable with resection, whereas diffuse lesions pose a significant challenge, with relapse in 90% of cases3. Head and neck AVMs require expert management and a multidisciplinary approach. The team may consist of neurosurgery, neuro‐endovascular,plastic surgery, and dermatology services. Treatment options include medical management, surgical resection, endovascular and percutaneous embolization. Percutaenous n‐BCA embolization is employed to prevent hemorrhage during surgical resection, or stabilization in acute hemorrhage4,5. This holds especially true when an endovascular approach is difficult; typically due to tortuous vasculature5. Treatment may require a staged target approach, with endovascular or percutaneous embolization prior to surgical excision. Conclusions This case highlights the complexities of AVM management and the multidisciplinary approach necessary, to provide optimal care. In this case, we believe that pregnancy could have contributed to the overall change in aggressive nature of the AVM. The patient underwent emergent percutaneous and endovascular embolization to prevent life threatening hemorrhage followed by palliative embolization to avoid long term cervical spinal cord injury due to venous hypertension.
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