Significance of recanalization of sinuses and resolution of parenchymal lesion in cerebral venous sinus thrombosis

In cerebral venous sinus thrombosis (CVST), the degree of recanalization may determine resolution of parenchymal lesion and clinical outcome. The aim of our study was to evaluate the relationship of recanalization with resolution of MRI lesion and clinical outcome.The patients with CVST diagnosed on the basis of magnetic resonance venography (MRV) were included prospectively. Risk factors, clinical features, and MRI and MRV findings were noted. MRI and MRV were repeated at 6 months and the change in parenchymal lesion and grade of recanalization (I, II, III) were noted. Patients were evaluated clinically at three and six months. Complete recovery was considered if modified Rankin Scale (mRS) score was 0.Thirty-three CVST patients were included, 12 (36.4%) of whom were females. Recanalization occurred in 29 (87.9%), which was complete (grade III) in 6 (21%). Sigmoid sinus (52%) recanalized more frequently. Resolution of parenchymal lesion on repeat MRI occurred in 13.3% (4/30) patients, and they had no sequelae. Degree of recanalization was not related to resolution of neurological sequelae, MRI lesion at follow up and burden of thrombosis at baseline.Varying degree of recanalization occurred in 87.9% patients with CVST, and resolution of parenchymal lesion occurred in 13.3%. Clinical outcome however was not related to recanalization.     

Utility of heavily T2-weighted MR myelography as the first step in CSF leak detection and the planning of epidural blood patches

Heavily T2-weighted MR myelography (HT2W-MRM) is emerging as an alternative approach for detection and follow up of CSF leaks. We aimed to assess epidural blood patch (EBP) treatment outcome when using HT2W-MRM as the primary modality for detecting CSF leak and planning EBP placement in routine clinical practice. Since 2018, patients at our institute suspected of having CSF leak, routinely HT2W-MRM instead of CT myelography to determine presence of the leak and identify the EBP target site. Fifty-nine consecutive patients suspected of having a CSF leak underwent HT2W-MRM. After excluding patients with subdural hematoma and poor image quality, 26 (10 men, 16 women; mean age 44.92 ± 12.6 years) patients were included in this study. Patients received EBP on the basis of HT2W-MRM assessments and clinical assessment. Imaging findings and clinical outcome were evaluated. CSF leak was identified in 21 patients (80.8%, 21/26) based HT2W-MRM. Most cases were graded on a confidence scale as CSF leak definitely (n = 13) or probably (n = 3) present. Successful clinical EBP treatment was achieved in 14 of 17 patients (82.4%) after first targeted EBP, and patient symptoms significantly improved after treatment (numerical rating score 6.4 before EBP, 1.3 after EBP, P < 0.001). HT2W-MRM based EBP are the rational and effective choices for CSF leak treatment in routine clinical practice.     

Arterial and venous strokes in the setting of COVID-19

Background and purposeCoronavirus disease 2019 (COVID-19) is a global pandemic that causes flu-like symptoms. There is a growing body of evidence suggesting that both the central and peripheral nervous systems can be affected by SARS-CoV-2, including stroke. We present three cases of arterial ischemic strokes and one venous infarction from a cerebral venous sinus thrombosis in the setting of COVID-19 infection who otherwise had low risk factors for stroke.MethodsWe retrospectively reviewed patients presenting to a large tertiary care academic US hospital with stroke and who tested positive for COVID-19. Medical records were reviewed for demographics, imaging results and lab findings.ResultsThere were 3 cases of arterial ischemic strokes and 1 case of venous stroke: 3 males and 1 female. The mean age was 55 (48–70) years. All arterial strokes presented with large vessel occlusions and had mechanical thrombectomy performed. Two cases presented with stroke despite being on full anticoagulation.ConclusionsIt is important to recognize the neurological manifestations of COVID-19, especially ischemic stroke, either arterial or venous in nature. Hypercoagulability and the cytokine surge are perhaps the cause of ischemic stroke in these patients. Further studies are needed to understand the role of anticoagulation in these patients.     

Cerebral venous thrombosis in COVID-19-associated coagulopathy: A case report

COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was first reported in Wuhan, China in December 2019, and is ongoing pandemic. While a majority of patients with SARS-CoV-2 infection shows asymptomatic or mild disease, hospitalized patients can develop critical condition, such as pneumonia, sepsis, and respiratory failure. Some cases deteriorate into sever systemic disease and multiorgan failure. Many patients of severe COVID-19 show hypercoagulable state and complicate with venous thromboembolism and atrial thrombosis. We herein reported a case of COVID-19 who developed cerebral venous thrombosis (CVT) co-incidence with pulmonary thromboembolism (PTE). A 56-year-old Japanese man was presented with fever and malaise and diagnosed with COVID-19. He was treated with ciclesonide and azithromycin, but his respiratory condition deteriorated. Thus, systemic corticosteroids and favipiravir were initiated and these treatments resulted in afebrile state, improving malaise and respiratory failure. However, he suddenly developed severe headache and vomiting with increased concentration of D-dimer. Brain CT and MRI showed typical images of CVT in the left transvers sinus and CT pulmonary angiography showed PE. Administration of unfractionated heparin followed by edoxaban treatment reduced the levels of D-dimer and improved his clinical presentation and thrombosis. Monitoring coagulopathy is important in COVID-19 patients and in case of venous thromboembolism, including cerebral venous system, appropriate anticoagulant therapy should be initiated.     

Cognitive behavioral therapy reduces illness perceptions and anxiety symptoms in patients with unruptured intracranial aneurysm

The main purpose of this study was to assess the relation between cognitive behavioral therapy and possible changes in illness perceptions and anxiety in patients diagnosed with unruptured intracranial aneurysm. An observational study of an intervention with 67 patients with an unruptured intracranial aneurysm from two medical centers in a Colombian city (n = 35 on the intervention group) was carried out. To assess changes, measurements were taken at baseline and at one-year follow-up with the Beck Anxiety Inventory and the Illness Perception Questionnaire, brief version, taking into account the importance of perceptions in the process of adjusting to illness and acquiring healthy life habits. Hypotheses were tested by a structural model. The results obtained from this study showed that illness perceptions were related to anxiety levels at both time points; however, the relations were stronger before cognitive behavioral therapy (βt0 = 0.61, p < 0.01; βt1 = 0.37, p < 0.01). Cognitive behavioral therapy was found to be a moderator of changes in both illness perceptions and anxiety at the time of follow-up (β = −0.31, p < 0.01; β = −0.26, p < 0.01). The structural model suggests that cognitive behavioral therapy is associated with less anxiety (β = −0.17, p < 0.05) and better illness perceptions (β = −0.35, p < 0.01) in patients diagnosed with unruptured intracranial aneurysms.     

Multiple intra-aneurysmal WEB devices: Case discussions and operative technique

The Woven Endobridge (WEB, Sequent Medical, Aliso Viejo, California) device has emerged as an FDA approved endosaccular flow diverting alternative for patients with complex aneurysm morphology. We describe for the first time, in patients with dual anti platelet therapy (DAPT) non compliance, two cases during which multiple WEB devices were deployed within the aneurysm sac to achieve flow disruption. Two ophthalmic segment internal carotid artery aneurysms are treated by the deployment of an additional WEB device within the sac. We subsequently discuss the techniques utilized to ensure parent vessel patency. We demonstrate that patients with contraindications to endovascular modalities requiring DAPT may be candidates for a multi WEB intra-aneurysmal construct.     

血流导向装置治疗颅内大型未破裂动脉瘤的临床疗效分析

目的探讨血流导向装置(FD)治疗颅内大型未破裂动脉瘤的安全性及疗效。方法回顾性分析郑州大学人民医院(河南省人民医院)脑血管介入科2015年2月至2019年7月应用FD(Pipeline+Tubridge)治疗的颅内大型(最大径≥10 mm)未破裂动脉瘤患者的临床资料,共92例(95个动脉瘤)。采用改良Rankin量表评分(mRS)标准评价临床预后,采用O′Kelly-Marotta(OKM)分级标准评估动脉瘤闭塞情况;采用多因素logistic回归分析方法分析影响术后6个月动脉瘤完全闭塞的相关因素。结果92例患者95个动脉瘤共置入101枚FD,手术成功率为100%。术后神经系统并发症发生率为4.3%(4/92),其中缺血性1例,出血性2例(死亡1例),术后出现烦躁等症状1例。77例患者获临床随访,中位随访时间为12(1~51)个月。至末次随访,mRS 0分70例,1分5例,2分、3分各1例。55例患者(56个动脉瘤)行影像学随访,末次中位随访时间为6(3~29)个月,动脉瘤完全闭塞(OKM分级D级)40个(71.4%,40/56),支架内狭窄的发生率为7.1%(4/56)。52例患者(53个动脉瘤)6个月随访时动脉瘤完全闭塞34个(64.2%,34/53),支架内狭窄的发生率为7.5%(4/53)。多因素logistic回归分析显示,联合弹簧圈填塞是术后6个月时动脉瘤完全闭塞的独立影响因素(OR=8.98,95%CI:1.87~43.22,P=0.006)。结论FD治疗颅内大型未破裂动脉瘤的手术成功率高,安全性好,但应警惕严重并发症的发生;联合弹簧圈填塞可促进动脉瘤完全闭塞。     

Misleading non-epileptic epileptiform activities on intracranial recordings

Numerous non-epileptic physiological electroencephalographic (EEG) patterns morphologically mimic epileptiform activity. However, misleading non-epileptic findings of electrocorticography (ECoG) have not yet been examined in detail. The aim of the present study was to identify non-epileptic epileptiform ECoG findings. We retrospectively reviewed the intracranial recordings of 21 patients with intractable focal epilepsy who became seizure-free after a presurgical evaluation with subdural electrodes following resective surgeries at Sapporo Medical University between January 2014 and December 2018. Morphological epileptiform findings outside epileptogenic areas were judged as non-epileptic and analyzed. Seventeen areas in nine patients exhibited non-epileptic epileptiform activities. These areas were identified in the lateral temporal cortices, basal temporal areas, rolandic areas, and frontal lobe. Morphological patterns were classified into three types: 1) spiky oscillations, 2) isolated spiky activity, and 3) isolated fast activity. The normal cortex may exhibit non-epileptic epileptiform activities. These activities need to be carefully differentiated from real epileptic abnormalities to prevent the mislocalization of epileptogenic areas.     

Dural venous sinus thrombosis after cerebellopontine angle surgery: Should it be treated?

IntroductionDural venous sinus thrombosis is an uncommon, but significant sequela that may occur after resection of a cerebellopontine angle lesion. The natural history and management of this pathology has not been sufficiently studied.MethodsAll operative cases for cerebellopontine angle lesions performed in our local institution dating from 1 January 2005 to 30 June 2018 were retrospectively reviewed to identify patients who developed new post-operative dural venous sinus thrombosis. Patients who developed a significantly narrowed sinus without intrinsic thrombus were also identified. Progression of sinus thrombosis through time was followed, with comparisons made between complications amongst patients with and without a compromised sinus.ResultsOf the 126 patients, 20 were found to have new sinus thrombosis, with another 16 developing a critically narrowed sinus without intrinsic thrombus. These cases are significantly associated with translabyrinthine resection of acoustic schwannoma. 4 patients amongst the thrombosed group were commenced on additional therapeutic anticoagulation or antiplatelets, whilst the rest were observed. Based on available follow up imaging, 10/17 patients had significantly improved sinus thrombosis on serial imaging, including 8/14 amongst those not given additional anticoagulation. Patients with a compromised sinus demonstrated a higher rate of cerebrospinal fluid leak requiring blindsac procedures. When involving a dominant sinus, there is also an association of an increased requirement for permanent CSF diversion.ConclusionTherapeutic anticoagulation should be considered for symptomatic post-operative dural venous sinus thrombosis or if it involves a dominant sinus. Further prospective studies are warranted to better elucidate the risk-benefit justification of treatment for postoperative sinus thrombosis.     

Post-traumatic hydrocephalus following decompressive hemicraniectomy: Incidence and risk factors in a prospective cohort of severe TBI patients

BackgroundIn severe traumatic brain injury (TBI) patients undergoing decompressive hemicraniectomy (DHC), the rate of post-traumatic hydrocephalus (PTH) is high at 12–36%. Early diagnosis and shunt placement can improve outcomes. Herein, we examined the incidence of and predictors of PTH after craniectomy.MethodsA retrospective analysis of prospectively collected database of severe TBI patients at a single U.S. Level 1 trauma center from May 2000 to July 2014 was performed. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), bleeding pattern and time-to-cranioplasty were analyzed. Glasgow Outcome Scale (GOS) scores at 6 and 12-months were studied. Statistical significance was assessed at p < 0.05.ResultsA total of 402 patients were enrolled and 105 patients had DHC. Twenty-two (21.0%) of 105 required ventriculoperitoneal shunt (VPS), compared to 18 (6%) of 297 patients without DHC. There was increased odds ratio for shunting after DHC at 3.62 (95%CI:1.62–8.07; p < 0.01). Mean age at time of DHC was 43.8 ± 17.7 years old, and 81.9% were male. Subdural hematoma (SDH) was most common at 57.1%. Median time from admission to cranioplasty was 63 days. Patients who experienced PTH after DHC were younger (35.5 ± 17.7 versus 46.0 ± 17.7 years, p < 0.01) and had higher ISS scores (35 versus 26, p = 0.04) compared to patients without shunt after DHC.ConclusionsAfter severe TBI requiring hemicraniectomy, shunt-dependent hydrocephalus was 21%. Younger patients and higher ISS score were associated with PTH. Shunt-dependent patients achieved similar 6- and 12-month outcomes as those without PTH. Early diagnosis and shunt placement can enhance long-term neurological recovery.