Neurosurgical versus endovascular treatment of craniocervical junction arteriovenous fistulas: a multicenter cohort study of 97 patients

OBJECTIVE Craniocervical junction (CCJ) arteriovenous fistulas (AVFs) are treated using neurosurgical or endovascular options; however, there is still no consensus on the safest and most effective treatment. The present study compared the treatment results of neurosurgical and endovascular procedures for CCJ AVFs, specifically regarding retreatment, complications, and outcomes. METHODS This was a multicenter cohort study authorized by the Neurospinal Society of Japan. Data on consecutive patients with CCJ AVFs who underwent neurosurgical or endovascular treatment between 2009 and 2019 at 29 centers were analyzed. The primary endpoint was the retreatment rate by procedure. Secondary endpoints were the overall complication rate, the ischemic complication rate, the mortality rate, posttreatment changes in the neurological status, independent risk factors for retreatment, and poor outcomes. RESULTS Ninety-seven patients underwent neurosurgical (78 patients) or endovascular (19 patients) treatment. Retreatment rates were 2.6% (2/78 patients) in the neurosurgery group and 63% (12/19 patients) in the endovascular group (p < 0.001). Overall complication rates were 22% and 42% in the neurosurgery and endovascular groups, respectively (p = 0.084). Ischemic complication rates were 7.7% and 26% in the neurosurgery and endovascular groups, respectively (p = 0.037). Ischemic complications included 8 spinal infarctions, 2 brainstem infarctions, and 1 cerebellar infarction, which resulted in permanent neurological deficits. Mortality rates were 2.6% and 0% in the neurosurgery and endovascular groups, respectively (p > 0.99). Two patients died of systemic complications. The percentages of patients with improved modified Rankin Scale (mRS) scores were 60% and 37% in the neurosurgery and endovascular groups, respectively, with a median follow-up of 23 months (p = 0.043). Multivariate analysis identified endovascular treatment as an independent risk factor associated with retreatment (OR 54, 95% CI 9.9–300; p < 0.001). Independent risk factors associated with poor outcomes (a postoperative mRS score of 3 or greater) were a pretreatment mRS score of 3 or greater (OR 13, 95% CI 2.7–62; p = 0.001) and complications (OR 5.8; 95% CI 1.3–26; p = 0.020). CONCLUSIONS Neurosurgical treatment was more effective and safer than endovascular treatment for patients with CCJ AVFs because of lower retreatment and ischemic complication rates and better outcomes.

Colostomy Takedown: Ischemic Complication following Anorectal Malformation Surgery

Introduction. Anorectal malformations (ARM) are complex disorders that often require staged reconstructions. We present a case and imaging findings of a child who developed issues following colostomy closure due to segmental colonic ischemia. Case Presentation. A 3-year-old female with Currarino syndrome presented with abdominal distention, blood-flecked stools, and prolonged cecostomy flush time. For her anorectal malformation, a colostomy was initially placed. A new colostomy was created at posterior sagittal anorectoplasty (PSARP) to allow the distal rectum to reach the anus without tension. Differentials for her presenting symptoms included a mislocation of the anus, stenosis at the anoplasty site, stricture within the colon, or sacral mass from Currarino syndrome, causing obstructive symptoms. Workup at our hospital included an anorectal exam under anesthesia (EUA), which showed a well-located anus with without stenosis at the anoplasty site, and an antegrade contrast study revealed a featureless descending colon with a 3-4 mm stricture in the distal transverse colon at the site of the previous colostomy, without an obstructing presacral mass. To alleviate this obstruction, the child underwent removal of the chronically ischemic descending colon and a redo-PSARP, where the distal transverse colon was brought down to the anus. She is now able to successfully perform antegrade flushes. Conclusion. Patients who have had prior surgeries for ARM repair are at a higher risk of complications, including strictures or ischemic complications at areas of previous surgery or colostomy placement. A thorough preoperative workup, including contrast studies, can alert the surgeon to these potential pitfalls.

Acute hemorrhagic cerebral artery dissection: Characteristics and endovascular treatment

Objective Acute hemorrhagic cerebral artery dissection may show a subtle stenosis and bulge on an angiogram, for which diagnosis and treatment are difficult. This report describes seven cases of acute hemorrhagic cerebral artery dissection treated by endovascular techniques. Patients and methods From January 2018 to April 2019, seven patients (22–76 years old) were diagnosed with subarachnoid hemorrhage caused by cerebral artery dissection. Six patients were treated by low-profile visualized intraluminal support stent-assisted coiling and there was a sacrifice of the posterior cerebral artery in one patient. Cerebral angiography results were obtained immediately after intervention and at follow-up. Clinical outcome was evaluated by a modified Rankin Scale score. Results Four dissections were angiographic changes of subtle stenosis and small bulges; three were apparent angiographic changes of stenosis or fusiform morphologies. All seven aneurysms were completely obliterated, a low-profile visualized intraluminal support stent was used in six patients and coil occlusion of the parent artery in one patient. Complications occurred in two cases of proximal posterior cerebral artery dissection. One bleeding complication was observed intra-procedure and one ischemic complication was observed after stent-assisted coiling. The angiographic and clinical follow-up was obtained at 3–8 months in five patients. Good recovery was achieved for six patients (modified Rankin Score 0); one patient who presented Weber syndrome caused by ischemic complication had a modified Rankin Score of two at 8 months follow-up. Conclusion Hemorrhagic cerebral artery dissection may show subtle stenosis, small bulges or fusiform morphologies on angiograms. Treatment of proximal posterior cerebral artery dissection is challenging. Endovascular reconstruction with a low-profile visualized intraluminal support stent was effective depending on the angiographic morphology.

Flow diverters for ruptured posterior circulation perforator aneurysms: multicenter experience and literature review

BackgroundThe management of ruptured posterior circulation perforator aneurysms (rPCPAs) remains unclear. We present our experience in treating rPCPAs with flow diverter stents (FDs) and evaluate their safety and efficacy at mid- to long-term follow-up. A diagnostic and therapeutic algorithm for rPCPAs is also proposed.MethodsWe retrospectively analyzed data from all consecutive patients with rPCPAs treated with FDs at our institutions between January 2013 and July 2019. Clinical presentations, time of treatments, intra- and perioperative complications, and clinical and angiographic outcomes were recorded, with a mid- to long-term follow-up. A systematic review of the literature on rPCPAs treated with FDs was also performed.ResultsSeven patients with seven rPCPAs were treated with FDs. All patients presented with an atypical subarachnoid hemorrhage distribution and a low to medium Hunt–Hess grade. In 29% of cases rPCPAs were identified on the initial angiogram. In 57% of cases, FDs were inserted within 2 days of the diagnosis. Immediate aneurysm occlusion was observed in 14% of the cases and in 71% at the first follow-up (mean 2.4 months). At mean follow-up of 33 months (range 3–72 months) one case of delayed ischemic complication occurred. Six patients had a modified Rankin Scale (mRS) score of 0 and one patient had an mRS score of 4 at the latest follow-up.ConclusionsThe best management for rPCPAs remains unclear, but FDs seem to have lower complication rates than other treatment options. Further studies with larger series are needed to confirm the role of FDs in rPCPA.

Factors related to adverse events during endovascular coil embolization for ruptured cerebral aneurysms

Background and purposeThe risk factors for adverse events for example, intraprocedural rupture (IPR), ischemic complication within 24 hours, and rebleeding after endovascular coil embolization for a ruptured cerebral aneurysm remain unclear. The aim of this study was to identify significant associated risk factors.MethodsWe retrospectively evaluated data from 5358 patients listed on the Japanese Registry of Neuroendovascular Therapy 3 during 2010–2014.ResultsIPR, ischemic complications, and rebleeding occurred during or after 221 (4.1%), 226 (4.2%), and 63 (1.2%) treatments, respectively. All of the adverse events were significantly associated with the patients’ poor outcomes at 30 days. Multivariate analysis revealed the factors independently related to these adverse events as follows: (1) for IPR: female sex, bifurcation type, <5 mm aneurysm, emergent surgery, local anesthesia, a balloon-assisted technique; (2) for an ischemic complication: poor World Federation World Federation of Neurological Societies (WFNS) grade, wide neck, and stent-assisted technique; (3) for rebleeding: poor WFNS grade, bifurcation type, wide neck, and body filling as the initial result.ConclusionsKnowledge of the risk factors of endovascular coil embolization and paying attention to them are essential for patients’ safe treatment and good outcomes.

STMO-18 SUBPIAL RESECTION OF GLIOMA USING CUSA CLARITY

BACKGROUND Maximum safe resection is a primary goal of glioma surgery. Ultrasonic aspiration is commonly used technique in neurosurgery, as it allows for safely debulking of tumors without damaging the adjacent brain tissue. CUSA Clarity helps to avoid damage to blood vessels and nerve fibers due to its original function, ‘Tissue Select’. Here we introduce glioma surgery using CUSA Clarity. METHODS We used CUSA Clarity in three cases with glioma at Kyorin University Hospital. According to fragility of the tissues and hardness of the tumor, we adjusted power, irrigation, and Tissue Select level of CUSA Clarity. We also introduce subpial aspiration technique in glioma surgery using normal CUSA. RESULTS Histological diagnoses of the three patients were WHO grade IV glioblastoma, grade III anaplastic astrocytoma, and grade II oligodendroglioma. All patients underwent successful maximum safe resection without ischemic complication. CUSA Clarity allowed for safe subpial dissection and preservation of pia and small vessels more perfectly than surgery using normal CUSA. CUSA Clarity also contributed to bloodless dissection of the tumor margin due to avoidance of feeder injury. When using Tissue Select mode, the power of the CUSA was elevated by 10 or 20 to aspirate the tumor effectively. CONCLUSION CUSA Clarity contributes to safe resection of glioma due to selective tumor aspiration by Tissue Select.

NI-23 ULTRA-HIGH-RESOLUTION CT ANGIOGRAPHY FOR BRAIN TUMOR SURGERY

BACKGROUND Preoperative accurate evaluation of arteries and veins can help avoid ischemic complication of brain tumor surgery. The latest ultra-high-resolution CT (UHRCT) angiography (Aquilion PrecisionTM; Canon Medical Systems) has recently become available for clinical testing of the main arteries and critical perforating arteries by brain CTA, compared to conventional CT. METHODS UHRCT provides slice collimation of 0.25 mm x 160 and matrix size of 1024 x 1024 or 2048 x 2048. Major features of this CT scanner include an improved detector system (the minimal slice thickness, 0.25 mm; the maximal channel number, 1792) and a small x-ray focus (the smallest size, 0.4 x 0.5 mm) compared to a standard multi-detector CT (MDCT) scanner (the minimal slice thickness, 0.5 mm; the maximal channel number, 896; the smallest x-ray focus size, 0.8 x 0.9 mm). RESULTS Until July 2019, 168 patients with brain tumor underwent UHRCT angiography. As high resolution image could visualize cortical arteries and cortical veins clearly, it helped to decide approach route to the tumor and achieve accurate biopsy of even small lesion. Identification of tumor feeders and passing arteries allowed for efficient feeder coagulation and preservation of passing artery, avoiding the ischemic change of surrounding brain. Improved image reconstruction could visualize perforating arteries, which helped to preserve perforator by predicting the location during tumor removal. CONCLUSION UHRCT angiography can visualize even tiny arteries and veins around the tumor, and contributes to avoid the risk of ischemic complication.