Prevalence of Tinnitus in Patients Diagnosed with Cerebral Arteriovenous Fistula Treated with Endovascular Technique

Introduction Tinnitus is characterized as the conscious and involuntary perception of sound, and it affects ∼ 30% of the population. Despite careful physical examination, the etiology of tinnitus can be established for only 30% of patients. Tinnitus is a common symptom of cerebral arteriovenous fistulas and results from increased blood flow through the dural venous sinuses, leading to turbulent arterial flow, mainly related to sigmoid and transverse sinus lesions. Objectives To analyze the frequency of tinnitus, patient profile, and endovascular treatment characteristics in individuals diagnosed with cerebral arteriovenous fistulas. Methods A retrospective and observational study based on reviewed data from medical records on the PHILIPS Tasy system (Philips Healthcare, Cambridge, MA, USA) at the neurosurgery and interventional neuroradiology service of Hospital Santa Isabel in Blumenau–state of Santa Catarina, Brazil. Results The profile of 68 individuals diagnosed with cerebral arteriovenous fistula who underwent endovascular treatment were analyzed. Most patients were female, aged 31 to 60. Tinnitus affected 18 individuals. Dural fistulas were the most prevalent in the sample, and computed tomography alone was the most used diagnostic method for initial investigation. Conclusion The prevalence of this symptom in patients diagnosed with cerebral arteriovenous fistula was found in 26.5% of this sample, mainly in women with associated comorbidities. Tinnitus remission was observed in all patients who underwent endovascular treatment to correct cerebral fistula.

P.190 Choosing Endovascular Treatment or Thrombolysis in Patients with Pre-stroke Comorbidities: UNMASK EVT, a Worldwide Survey

Background: Decisions to treat large-vessel occlusion with endovascular therapy(EVT) or intravenous alteplase depend on how physicians weigh benefits against risks when considering patients’ pre-stroke comorbidities. Methods: In an international survey, experts chose treatment approaches under current resources and under assumed ideal conditions for 10 of 22 randomly assigned case-scenarios. Five included comorbidities(metastatic/non-metastatic cancer, cardiac/respiratory/renal disease, non-disabling/mild cognitive impairment[MCI], physical dependence). We examined scenario/respondent characteristics associated with EVT/alteplase decisions using multivariable logistic regressions. Results: Among 607 physicians(38 countries), EVT was favoured in 1,097/1,379(79.6%) responses for comorbidity-related scenarios under current resources versus 1,510/1,657(91.1%,OR:0.38, 95%CI.0.31-0.47) for six “level-1A” scenarios (assuming ideal conditions:82.7% vs 95.1%,OR:0.25,0.19-0.33). However, this was reversed on including all other scenarios(e.g. under current resources:3,489/4,691[74.4%], OR:1.34,1.17-1.54). Responses favouring alteplase for comorbidity-related(e.g.75.0% under current resources) scenarios were comparable to level-1A scenarios(72.2%) and higher than all others(60.4%). No comorbidity-related factor independently diminished EVT-odds. MCI and dependence carried higher alteplase-odds; cancer and cardiac/respiratory/renal disease had lower odds. Relevant respondent characteristics included performing more EVT cases/year (higher EVT, lower alteplase-odds), practicing in East-Asia (higher EVT-odds), and in interventional neuroradiology(lower alteplase-odds vs neurology). Conclusions: Moderate-to-severe comorbidities did not consistently deter experts from EVT, suggesting equipoise about withholding EVT based on comorbidities. However, alteplase was often foregone when respondents chose EVT.

Abstract 1122‐000124: Dural Arteriovenous Fistula and Implications in Aneurysmal Genesis

Introduction : There is a reported association of cerebral arteriovenous malformations and aneurysms, however, data regarding patients presenting with dural arteriovenous fistulas (dAVF) and aneurysms is limited. Here, we present a patient who was incidentally diagnosed with 2 aneurysms in addition to a dAVF; and her treatment course. Previous to her diagnosis, she denied any and all symptomatology that would prompt further evaluation. Methods : Case description: 60‐year‐old female with history of hypertension, hypothyroidism and gastroesophageal reflux disease who initially presented to an outside hospital after a motor vehicle collision in 2016, at that time she reports being diagnosed with multiple aneurysms; but was lost to follow up. In 2020 she was referred to interventional neuroradiology and underwent diagnostic digital cerebral angiogram. Which reported a 13 × 12 × 13.3 mm left para‐ophthalmic internal carotid artery (ICA) aneurysm with a 7 mm neck. A 5.7 × 7.7 × 6.1 mm basilar tip artery aneurysm with a 5.6 mm neck and a right Cognard type four occipital dAVF, with feeding vessels from the right posterior cerebral artery and right occipital artery and anterograde drainage to the dural sinuses. From the time of diagnosis to the initiation of interventions, patient denied any concerning symptomatology. Treatment was initiated 4 months after diagnostic angiogram. She received 5 days of Dual Antiplatelet therapy (DAPT) with aspirin and Plavix previous to the deployment of a woven endobridge device (WEB™ 8‐3mm) into the basilar tip aneurysm; as this was felt to be the aneurysm with highest probability of rupture. Post‐operative course was unremarkable and DAPT was discontinued. Three months after WEB™ deployment, the patient underwent embolization of the right occipital dAVF with a liquid embolic agent (onyx™). Post operatively, she developed decreased peripheral vision in her left eye, though the rest of her hospitalization was unremarkable. 3 months after embolization, she underwent left para‐ophthalmic artery aneurysm flow diversion with a pipeline™ (4‐18mm) flow diverter, with an uncomplicated admission. She was subsequently evaluated by neuro‐ophthalmology who has reported a stable peripheral left eye left inferior quadrantic defect along with a supertemporal defect in her right eye. Results : Discussion: Interestingly, the patient presented 2 aneurysms, one in the anterior circulation and the most concerning, located in the posterior circulation. One could draw conclusions that the dAVF was associated with the basilar aneurysm. As dAVFs are acquired lesions, it is feasible to assume that there may be an association between both types of lesions, perhaps due to flow or pressure being exerted on weakened vessel walls, thus leading to aneurysmal formation. Conclusions : Conclusion: Because a potential for implication in the flow dynamics of the dAVF in aneurysmal formation. We have opted to use computational fluid dynamics to analyze said flow within the dAVF to better understand the causal relationship between aneurysms and dural fistulae. In the long run research into genesis of aneurysms secondary to coexisting vascular lesions could further elucidate the mechanisms by which aneurysms develop.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital without neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)

Background The immediate management of subarachnoid hemorrhage (SAH) patients in hospitals without neurosurgical/neurointerventional facilities and their transfer to a specialized center is challenging and not well covered in existing guidelines. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance. Methods A multidisciplinary consensus panel composed by 19 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery and interventional neuroradiology) was created. A modified Delphi approach was adopted. Results A total of 14 statements have been discussed. Consensus was reached on 11 strong recommendations and 2 weak recommendations. In one case, where consensus could not be agreed upon, no recommendation could be provided. Conclusions Management of SAH in a non-specialized setting and early transfer are difficult and may have a critical impact on outcome. Clinical advice, based on multidisciplinary consensus, might be helpful. Our recommendations cover most, but not all, topics of clinical relevance.

Monitoring Radiation Doses during Diagnostic and Therapeutic Neurointerventional Procedures: Multicenter Study for Establishment of Reference Levels

Purpose: To assess patient radiation doses during diagnostic and therapeutic neurointerventional procedures from multiple centers and propose dose reference level (RL).Materials and Methods: Consecutive neurointerventional procedures, performed in 22 hospitals from December 2020 to June 2021, were retrospectively studied. We collected data from a sample of 429 diagnostic and 731 therapeutic procedures. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time (FT), and total number of image frames (NI) were obtained. RL were calculated as the 3rd quartiles of the distribution.Results: Analysis of 1160 procedures from 22 hospitals confirmed the large variability in patient dose for similar procedures. RLs in terms of DAP, CAK, FT, and NI were 101.6 Gy·cm², 711.3 mGy, 13.3 minutes, and 637 frames for cerebral angiography, 199.9 Gy·cm², 3,458.7 mGy, 57.3 minutes, and 1,000 frames for aneurysm coiling, 225.1 Gy·cm², 1,590 mGy, 44.7 minutes, and 800 frames for stroke thrombolysis, 412.3 Gy·cm², 4,447.8 mGy, 99.3 minutes, and 1,621.3 frames for arteriovenous malformation (AVM) embolization, respectively. For all procedures, the results were comparable to most of those already published. Statistical analysis showed male and presence of procedural complications were significant factors in aneurysmal coiling. Male, number of passages, and procedural combined technique were significant factors in stroke thrombolysis. In AVM embolization, a significantly higher radiation dose was found in the definitive endovascular cure group.Conclusion: Various RLs introduced in this study promote the optimization of patient doses in diagnostic and therapeutic interventional neuroradiology procedures. Proposed 3rd quartile DAP (Gy·cm²) values were 101.6 for diagnostic cerebral angiography, 199.9 for aneurysm coiling, 225.1 for stroke thrombolysis, and 412.3 for AVM embolization. Continual evolution of practices and technologies requires regular updates of RLs.

A clinical case of endovascular treatment of congenital intrahepatic arterioportal fistulae

The development and wide use of instrumental investigational methods, including multispiral computed tomography, computed tomography with angiography, duplex scanning of blood vessels, subtraction angiography, enabled diagnosis of rare diseases, in particular, of the intrahepatic arterioportal fistulae (IAPF). Methods of surgical treatment of this pathology include both open surgery and endovascular treatment with the use of embolizing implants or coils. The article presents a clinical case of diagnosis and endovascular treatment of IAPF in a 33‑year‑old patient, hospitalized in the Center of Interventional Neuroradiology at Feofaniya Clinical Hospital. The choice of the surgical treatment was based on the account of indications and contraindications to the intervention. The endovascular method was used: exclusion of the intrahepatic arterioportal fistulae by means of implantation of micro‑coils Nester 20 мм, MReye 20 mm, Tornado 10–4 mm. Positive dynamics was observed in the long‑term postoperative period (after 3 months), the control was performed based on such criteria as complaints’ absence, normalization of laboratory parameters, positive dynamics of the data of control hepatic angiography. IAPF elimination promoted the reduction of portal hypertension, and improvement of functional liver state. Endovascular method of treatment of patients with arterioportal fistulae is the method of choice at this pathology. The advantages of endovascular method include the minimization of intraoperative and postoperative complications, the shorter postoperative rehabilitation period. In case of the necessity for other method of surgical treatment, one should follow the indications and contraindications to the surgical intervention.

Use of Interventional Neuroradiology Devices (Solitaire AB and Cascade Net) In The Treatment of Complex Renal Aneurysms Through Stent-Assisted Coil Embolisation.

Introduction: The risk of rupture of true renal artery aneurysms is low but when they are bigger than 2 - 2.5 cm it increases significantly, making treatment essential. The need to use alternatives to conventional techniques in order to avoid predictable complications as coil migration is mandatory.Discussion: Routinely-used techniques in interventional neuroradiology such as flow diverters or those assisted with an occlusion balloon or stent have are suitable alternatives for complex aneurysms.Conclusion: Interventional neuroradiology devices such as the Cascade Net stent (Perflow Medical and Grupo Logsa) and Solitaire AB stent retriever (Medtronic) are valid and safe options. We describe the technique of such devices.

Common ground, different path: Ulnar artery access for interventional neurovascular procedures

Background Recently, radial artery access has gained popularity for interventional neurovascular procedures due to patient comfort and fewer complications. However, there are instances where the radial artery approach is not feasible. In such cases, trans-ulnar artery access (TUA) can offer an alternate route. There is limited data regarding neuro-interventional procedures performed via this approach. This study aims to evaluate the feasibility and safety of trans-ulnar approach for a wide range of interventional neurovascular procedures. Materials and methods The data for all patients who underwent ulnar artery access for diagnostic or interventional neuroradiology procedures was retrospectively collected between September 2020 and March 2021. Patient demographics, procedural details, procedure success, and complications were recorded. Results During the study period, 23 patients underwent 24 trans-ulnar approach procedures. The mean age of patients was 50.1 ± 14.2 years. Fourteen diagnostic cerebral angiograms and ten interventional procedures were performed. All procedures were successfully completed via trans-ulnar approach without a switch to alternate access. No major access site complication was observed. Conclusion Ulnar artery access is a safe and feasible option for neurovascular procedures. It can be effectively utilized for diagnostic cerebral angiography and a wide range of interventional procedures.