Endovascular management of multiple intracranial dural arteriovenous fistulas

Background and purposeMultiply occurring intracranial dural arteriovenous fistulas (dAVFs) have been documented but rarely occur, and neither pathogenesis nor prognosis is clearly understood. This study was conducted to analyze angiographic characteristics of multiple dAVFs and to chronicle our treatment experience.MethodsBetween April, 2002 and January, 2018, data prospectively collected from 310 patients with intracranial dAVFs were systematically reviewed, assessing clinical and anatomic outcomes of endovascular treatment in 32 patients with multiple dAVFs (≥ 2 fistulas each). Lesions were categorized as multifocal or diffuse type, depending on presentation, and further characterized as progressive or non-progressive disease.ResultsOverall, 18 patients (56.3%) experienced aggressive presentations, including intracerebral hemorrhage or venous infarction. Cortical venous reflux (CVR) was observed in 26 patients (81.3%), and sinus thrombosis or occlusion was seen in 24 (75.0%). Clinical outcomes in patients with multifocal fistulas (n = 11) were excellent (100%), marked by a moderately high rate of complete occlusion (54.5%). Those with progressive disease (n = 10) regularly displayed certain angiographic findings, namely diffuse configuration (100%), sinus thrombosis (100%), and CVR (100%). Complete anatomic obliteration was achieved in 12 patients (37.5%), and in 26 patients (81.3%), clinical outcomes were favorable.ConclusionMultiple dAVFs are typically aggressive at presentation, given strong associations with CVR and sinus thrombosis. In diffuse-type fistulas, the potential to recur or progress is high. Although definitive treatment poses a challenge, outcomes of endovascular therapeutics may be still optimized in this setting through strategic procedural modifications and careful follow-up monitoring.     

Hypertensive Crisis during Microwave Ablation of Adrenal Neoplasms: A Retrospective Analysis of Predictive Factors

PurposeTo identify risk factors for hypertensive crisis (HC) during ultrasound-guided percutaneous microwave (MW) ablation of adrenal neoplasms.Materials and MethodsPatients who underwent MW ablation for adrenal tumors between April 2006 and November 2017 were retrospectively identified for this study (51 consecutive patients; 35 males, 16 females; mean age, 55 years; range, 15–85 years). A total of 77 MW ablation treatments were performed for 67 tumors (24 primary [9 pheochromocytomas, 8 adenomas, and 7 cortical carcinomas]; and 43 metastases [22 hepatocellular carcinoma, 8 renal cell carcinoma, 5 non-small cell lung cancer, 4 colorectal cancer, 3 liposarcoma, and 1 malignant fibrous histiocytoma]). The mean diameter of the adrenal tumors was 4.6 cm (range, 1.2–16.2 cm). Information about patient demographics, imaging studies, pathology and laboratory results, procedure records, and clinical outcomes was retrieved and analyzed. Statistical analysis was then performed to determine potential risk factors for HC.ResultsOf the 77 MW ablation procedures, HC occurred in 13 (16.9%). A significantly higher risk of HC was observed in patients with pheochromocytoma (odds ratio [OR], 9.037; 95% confidence interval [CI], 1.731–47.172; P = .009), body mass index <24 kg/m² (OR, 5.167; 95% CI, 1.060–25.194; P = .042), dominant tumor size ≤4.5 cm (OR, 4.023; 95% CI, 1.011–16.005; P = .048), and pre-procedural systolic blood pressure ≥130 mmHg (OR, 0.242; 95% CI, 0.068–0.861; P = .029).ConclusionHC can occur during MW ablation in patients with either primary or metastatic adrenal tumors. Pheochromocytoma, body mass index, tumor size, and pre-procedural systolic blood pressure appear to be significant risk factors for the occurrence of HC.     

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage

BackgroundPatients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions.MethodsThis was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention.ResultsOf these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2–7.2 95 CI) had neurological decline, 73 (7.5% 5.9–9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5–7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1–0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305.ConclusionsRHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.     

Efeitos do sulfato de magnésio e da milrinona sobre o vasoespasmo cerebral após hemorragia subaracnoidea por aneurisma: estudo randômico

Background

Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage.

Development and validation of a novel scoring system to predict severe intraventricular hemorrhage in very low birth weight infants

ObjectiveWe sought to develop and validate a novel scoring system for the prediction of severe intraventricular hemorrhage (SIVH) in very low birth weight infants (VLBWI).MethodsThis retrospective cohort multicenter study included 615 VLBWI born between 24 and 32 weeks gestational age (GA). Multivariable logistic regression analyses were used to determine which factors evaluated within the first 5 days of life were associated with SIVH and the weights of these variables. The accuracy of the predictive scoring system was prospectively tested in the same units.ResultsThe final SIVH scoring system included the following variables: antenatal steroid therapy, GA, birth weight (BW), 1-min Apgar score, mechanical ventilation and hypotension. The SIVH scores used to divide the subjects into three tiers (low-risk (<5), moderate-risk (5–8) and high-risk (>8)) were developed based on these variables. Of infants with a score below 5, 1.2% (4/339) developed SIVH. Of those with a score above 8, 42.5% (17/40) developed SIVH. The scores were successfully verified in 99 VLBWI.ConclusionsThese findings suggest that among infants with a score >8, the incidence of SIVH is significantly higher. This scoring system can be used to predict the incidence of SIVH during the first 5 days after birth and may contribute to the early intervention in and prevention of SIVH.     

Resuscitative Endovascular Balloon Occlusion of the Aorta: A Review for Emergency Clinicians

BackgroundNon-compressible torso hemorrhage (NCTH) is difficult to control and associated with significant mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes an infra-diaphragmatic approach to control NCTH and is less invasive than resuscitative thoracotomy (RT). This article highlights the evidence for REBOA and provides an overview of the indications, procedural steps, and complications in adults for emergency clinicians.DiscussionTraumatic hemorrhage can be life threatening. Patients in extremis, whether from NCTH or exsanguination from other sites, may require RT with aortic cross-clamping. REBOA offers another avenue for proximal hemorrhage control and can be completed by emergency clinicians. The American College of Surgeons Committee on Trauma and the American College of Emergency Physicians recently released a joint statement detailing the indications for REBOA in adults. The evidence behind its use remains controversial, with significant heterogeneity among studies. Most studies demonstrate improved blood pressure without a significant improvement in mortality. Procedural steps include arterial access (most commonly the common femoral artery), positioning the initial sheath, balloon preparation and positioning, balloon inflation, securing the balloon/sheath, subsequent hemorrhage control, balloon deflation, and balloon/sheath removal. Several major complications can occur with REBOA placement. Future studies should evaluate training protocols, the role of simulation, and which target populations would benefit most from REBOA.ConclusionsREBOA can provide proximal hemorrhage control and can be performed by emergency clinicians. This article evaluates the evidence, indications, procedure, and complications for emergency clinicians.     

非高血压脑出血病因学研究进展

在非高血压性ICH病因中，脑血管结构病变如脑AVMs、海绵状血管瘤、rete MCA等可能通过 病变局部血管结构及血流动力学的变化导致患者ICH风险增加；抗凝药和溶栓药物的应用可能通过 改变患者血液凝结状态导致ICH；目前还发现抗抑郁药物等其他药物也有潜在导致患者ICH发生的风 险，其机制尚不明确。研究还发现，一些全身性因素如血糖异常、肝功能异常，甚至儿童时期的生长 暴露也可能影响患者的ICH风险。     

Hemorrhage promotes chronic adverse remodeling in acute myocardial infarction: a T1, T2 and BOLD study

Hemorrhage is recognized as a new independent predictor of adverse outcomes following acute myocardial infarction. However, the mechanisms of its effects are less understood. The aim of our study was to probe the downstream impact of hemorrhage towards chronic remodeling, including inflammation, vasodilator function and matrix alterations in an experimental model of hemorrhage. Myocardial hemorrhage was induced in the porcine heart by intracoronary injection of collagenase. Animals (N = 18) were subjected to coronary occlusion followed by reperfusion in three groups (six/group): 8 min ischemia with hemorrhage (+HEM), 45 min infarction with no hemorrhage (I ? HEM) and 45 min infarction with hemorrhage (I + HEM). MRI was performed up to 4 weeks after intervention. Cardiac function, edema (T₂, T₁), hemorrhage (T₂*), vasodilator function (T₂ BOLD), infarction and microvascular obstruction (MVO) and partition coefficient (pre‐ and post‐contrast T₁) were computed. Hemorrhage was induced only in the +HEM and I + HEM groups on Day 1 (low T₂* values). Infarct size was the greatest in the I + HEM group, while the +HEM group showed no observable infarct. MVO was seen only in the I + HEM group, with a 40% occurrence rate. Function was compromised and ventricular volume was enlarged only in the hemorrhage groups and not in the ischemia‐alone group. In the infarct zone, edema and matrix expansion were the greatest in the I + HEM group. In the remote myocardium, T₂ elevation and matrix expansion associated with a transient vasodilator dysfunction were observed in the hemorrhage groups but not in the ischemia‐alone group. Our study demonstrates that the introduction of myocardial hemorrhage at reperfusion results in greater myocardial damage, upregulated inflammation, chronic adverse remodeling and remote myocardial alterations beyond the effects of the initial ischemic insult. A systematic understanding of the consequences of hemorrhage will potentially aid in the identification of novel therapeutics for high‐risk patients progressing towards heart failure.