Publications by authors named "Giuseppe Lanzino"

516 Publications

Baseline Characteristics of Patients With Cavernous Angiomas With Symptomatic Hemorrhage in Multisite Trial Readiness Project.

Stroke 2021 Sep 16:STROKEAHA120033487. Epub 2021 Sep 16.

Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.).

Background And Purpose: Brain cavernous angiomas with symptomatic hemorrhage (CASH) have a high risk of neurological disability from recurrent bleeding. Systematic assessment of baseline features and multisite validation of novel magnetic resonance imaging biomarkers are needed to optimize clinical trial design aimed at novel pharmacotherapies in CASH.

Methods: This prospective, multicenter, observational cohort study included adults with unresected, adjudicated brain CASH within the prior year. Six US sites screened and enrolled patients starting August 2018. Baseline demographics, clinical and imaging features, functional status (modified Rankin Scale and National Institutes of Health Stroke Scale), and patient quality of life outcomes (Patient-Reported Outcomes Measurement Information System-29 and EuroQol-5D) were summarized using descriptive statistics. Patient-Reported Outcomes Measurement Information System-29 scores were standardized against a reference population (mean 50, SD 10), and one-sample test was performed for each domain. A subgroup underwent harmonized magnetic resonance imaging assessment of lesional iron content with quantitative susceptibility mapping and vascular permeability with dynamic contrast-enhanced quantitative perfusion.

Results: As of May 2020, 849 patients were screened and 110 CASH cases enrolled (13% prevalence of trial eligible cases). The average age at consent was 46±16 years, 53% were female, 41% were familial, and 43% were brainstem lesions. At enrollment, ≥90% of the cohort had independent functional outcome (modified Rankin Scale score ≤2 and National Institutes of Health Stroke Scale score <5). However, perceived health problems affecting quality of life were reported in >30% of patients (EuroQol-5D). Patients had significantly worse Patient-Reported Outcomes Measurement Information System-29 scores for anxiety (=0.007), but better depression (=0.002) and social satisfaction scores (=0.012) compared with the general reference population. Mean baseline quantitative susceptibility mapping and permeability of CASH lesion were 0.45±0.17 ppm and 0.39±0.31 mL/100 g per minute, respectively, which were similar to historical CASH cases and consistent across sites.

Conclusions: These baseline features will aid investigators in patient stratification and determining the most appropriate outcome measures for clinical trials of emerging pharmacotherapies in CASH.
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http://dx.doi.org/10.1161/STROKEAHA.120.033487DOI Listing
September 2021

Assessing the rate, natural history, and treatment trends of intracranial aneurysms in patients with intracranial dural arteriovenous fistulas: a Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) investigation.

J Neurosurg 2021 Sep 10:1-10. Epub 2021 Sep 10.

Departments of18Neurological Surgery.

Objective: There is a reported elevated risk of cerebral aneurysms in patients with intracranial dural arteriovenous fistulas (dAVFs). However, the natural history, rate of spontaneous regression, and ideal treatment regimen are not well characterized. In this study, the authors aimed to describe the characteristics of patients with dAVFs and intracranial aneurysms and propose a classification system.

Methods: The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database from 12 centers was retrospectively reviewed. Analysis was performed to compare dAVF patients with (dAVF+ cohort) and without (dAVF-only cohort) concomitant aneurysm. Aneurysms were categorized based on location as a dAVF flow-related aneurysm (FRA) or a dAVF non-flow-related aneurysm (NFRA), with further classification as extra- or intradural. Patients with traumatic pseudoaneurysms or aneurysms with associated arteriovenous malformations were excluded from the analysis. Patient demographics, dAVF anatomical information, aneurysm information, and follow-up data were collected.

Results: Of the 1077 patients, 1043 were eligible for inclusion, comprising 978 (93.8%) and 65 (6.2%) in the dAVF-only and dAVF+ cohorts, respectively. There were 96 aneurysms in the dAVF+ cohort; 10 patients (1%) harbored 12 FRAs, and 55 patients (5.3%) harbored 84 NFRAs. Dural AVF+ patients had higher rates of smoking (59.3% vs 35.2%, p < 0.001) and illicit drug use (5.8% vs 1.5%, p = 0.02). Sixteen dAVF+ patients (24.6%) presented with aneurysm rupture, which represented 16.7% of the total aneurysms. One patient (1.5%) had aneurysm rupture during follow-up. Patients with dAVF+ were more likely to have a dAVF located in nonconventional locations, less likely to have arterial supply to the dAVF from external carotid artery branches, and more likely to have supply from pial branches. Rates of cortical venous drainage and Borden type distributions were comparable between cohorts. A minority (12.5%) of aneurysms were FRAs. The majority of the aneurysms underwent treatment via either endovascular (36.5%) or microsurgical (15.6%) technique. A small proportion of aneurysms managed conservatively either with or without dAVF treatment spontaneously regressed (6.2%).

Conclusions: Patients with dAVF have a similar risk of harboring a concomitant intracranial aneurysm unrelated to the dAVF (5.3%) compared with the general population (approximately 2%-5%) and a rare risk (0.9%) of harboring an FRA. Only 50% of FRAs are intradural. Dural AVF+ patients have differences in dAVF angioarchitecture. A subset of dAVF+ patients harbor FRAs that may regress after dAVF treatment.
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http://dx.doi.org/10.3171/2021.1.JNS202861DOI Listing
September 2021

Recurrence after cure in cranial dural arteriovenous fistulas: a collaborative effort by the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR).

J Neurosurg 2021 Sep 10:1-9. Epub 2021 Sep 10.

Departments of18Neurological Surgery.

Objective: Cranial dural arteriovenous fistulas (dAVFs) are often treated with endovascular therapy, but occasionally a multimodality approach including surgery and/or radiosurgery is utilized. Recurrence after an initial angiographic cure has been reported, with estimated rates ranging from 2% to 14.3%, but few risk factors have been identified. The objective of this study was to identify risk factors associated with recurrence of dAVF after putative cure.

Methods: The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) data were retrospectively reviewed. All patients with angiographic cure after treatment and subsequent angiographic follow-up were included. The primary outcome was recurrence, with risk factor analysis. Secondary outcomes included clinical outcomes, morbidity, and mortality associated with recurrence. Risk factor analysis was performed comparing the group of patients who experienced recurrence with those with durable cure (regardless of multiple recurrences). Time-to-event analysis was performed using all collective recurrence events (multiple per patients in some cases).

Results: Of the 1077 patients included in the primary CONDOR data set, 457 met inclusion criteria. A total of 32 patients (7%) experienced 34 events of recurrence at a mean of 368.7 days (median 192 days). The recurrence rate was 4.5% overall. Kaplan-Meier analysis predicted long-term recurrence rates approaching 11% at 3 years. Grade III dAVFs treated with endovascular therapy were statistically significantly more likely to experience recurrence than those treated surgically (13.3% vs 0%, p = 0.0001). Tentorial location, cortical venous drainage, and deep cerebral venous drainage were all risk factors for recurrence. Endovascular intervention and radiosurgery were associated with recurrence. Six recurrences were symptomatic, including 2 with hemorrhage, 3 with nonhemorrhagic neurological deficit, and 1 with progressive flow-related symptoms (decreased vision).

Conclusions: Recurrence of dAVFs after putative cure can occur after endovascular treatment. Risk factors include tentorial location, cortical venous drainage, and deep cerebral drainage. Multimodality therapy can be used to achieve cure after recurrence. A delayed long-term angiographic evaluation (at least 1 year from cure) may be warranted, especially in cases with risk factors for recurrence.
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http://dx.doi.org/10.3171/2021.1.JNS202033DOI Listing
September 2021

Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR): rationale, design, and initial characterization of patient cohort.

J Neurosurg 2021 Sep 10:1-11. Epub 2021 Sep 10.

6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.

Objective: Cranial dural arteriovenous fistulas (dAVFs) are rare lesions, hampering efforts to understand them and improve their care. To address this challenge, investigators with an established record of dAVF investigation formed an international, multicenter consortium aimed at better elucidating dAVF pathophysiology, imaging characteristics, natural history, and patient outcomes. This report describes the design of the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) and includes characterization of the 1077-patient cohort.

Methods: Potential collaborators with established interest in the field were identified via systematic review of the literature. To ensure uniformity of data collection, a quality control process was instituted. Data were retrospectively obtained.

Results: CONDOR comprises 14 centers in the United States, the United Kingdom, the Netherlands, and Japan that have pooled their data from 1077 dAVF patients seen between 1990 and 2017. The cohort includes 359 patients (33%) with Borden type I dAVFs, 175 (16%) with Borden type II fistulas, and 529 (49%) with Borden type III fistulas. Overall, 852 patients (79%) presented with fistula-related symptoms: 427 (40%) presented with nonaggressive symptoms such as tinnitus or orbital phenomena, 258 (24%) presented with intracranial hemorrhage, and 167 (16%) presented with nonhemorrhagic neurological deficits. A smaller proportion (224 patients, 21%), whose dAVFs were discovered incidentally, were asymptomatic. Many patients (85%, 911/1077) underwent treatment via endovascular embolization (55%, 587/1077), surgery (10%, 103/1077), radiosurgery (3%, 36/1077), or multimodal therapy (17%, 184/1077). The overall angiographic cure rate was 83% (758/911 treated), and treatment-related permanent neurological morbidity was 2% (27/1467 total procedures). The median time from diagnosis to follow-up was 380 days (IQR 120-1038.5 days).

Conclusions: With more than 1000 patients, the CONDOR registry represents the largest registry of cranial dAVF patient data in the world. These unique, well-annotated data will enable multiple future analyses to be performed to better understand dAVFs and their management.
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http://dx.doi.org/10.3171/2021.1.JNS202790DOI Listing
September 2021

Dural arteriovenous fistulas without cortical venous drainage: presentation, treatment, and outcomes.

J Neurosurg 2021 Sep 10:1-9. Epub 2021 Sep 10.

16Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts.

Objective: Current evidence suggests that intracranial dural arteriovenous fistulas (dAVFs) without cortical venous drainage (CVD) have a benign clinical course. However, no large study has evaluated the safety and efficacy of current treatments and their impact over the natural history of dAVFs without CVD.

Methods: The authors conducted an analysis of the retrospectively collected multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database. Patient demographics and presenting symptoms, angiographic features of the dAVFs, and treatment outcomes of patients with Borden type I dAVFs were reviewed. Clinical and radiological follow-up information was assessed to determine rates of new intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND), worsening of venous hyperdynamic symptoms (VHSs), angiographic recurrence, and progression or spontaneous regression of dAVFs over time.

Results: A total of 342 patients/Borden type I dAVFs were identified. The mean patient age was 58.1 ± 15.6 years, and 62% were women. The mean follow-up time was 37.7 ± 54.3 months. Of 230 (67.3%) treated dAVFs, 178 (77%) underwent mainly endovascular embolization, 11 (4.7%) radiosurgery alone, and 4 (1.7%) open surgery as the primary modality. After the first embolization, most dAVFs (47.2%) achieved only partial reduction in early venous filling. Multiple complementary interventions increased complete obliteration rates from 37.9% after first embolization to 46.7% after two or more embolizations, and 55.2% after combined radiosurgery and open surgery. Immediate postprocedural complications occurred in 35 dAVFs (15.2%) and 6 (2.6%) with permanent sequelae. Of 127 completely obliterated dAVFs by any therapeutic modality, 2 (1.6%) showed angiographic recurrence/recanalization at a mean of 34.2 months after treatment. Progression to Borden-Shucart type II or III was documented in 2.2% of patients and subsequent development of a new dAVF in 1.6%. Partial spontaneous regression was found in 22 (21.4%) of 103 nontreated dAVFs. Multivariate Cox regression analysis demonstrated that older age, NHND, or severe venous-hyperdynamic symptoms at presentation and infratentorial location were associated with worse prognosis. Kaplan-Meier curves showed no significant difference for stable/improved symptoms survival probability in treated versus nontreated dAVFs. However, estimated survival times showed better trends for treated dAVFs compared with nontreated dAVFs (288.1 months vs 151.1 months, log-rank p = 0.28). This difference was statistically significant for treated dAVFs with 100% occlusion (394 months, log-rank p < 0.001).

Conclusions: Current therapeutic modalities for management of dAVFs without CVD may provide better symptom control when complete angiographic occlusion is achieved.
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http://dx.doi.org/10.3171/2021.1.JNS202825DOI Listing
September 2021

Acute Pseudoaneurysms and Hemorrhage After Transcarotid Artery Revascularization.

Neurol Clin Pract 2021 Jun;11(3):e370-e372

Departments of Neurology (TC, EFW); Neurosurgery (WB, GL); and Vascular Surgery (RRD), Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1212/CPJ.0000000000000844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382364PMC
June 2021

Introduction. Translational research advances in the evaluation and management of moyamoya disease.

Neurosurg Focus 2021 09;51(3):E1

4Department of Neurosurgery, Huashan Hospital, Shanghai, China.

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http://dx.doi.org/10.3171/2021.6.FOCUS21373DOI Listing
September 2021

Outcome Following Hemorrhage From Cranial Dural Arteriovenous Fistulae: Analysis of the Multicenter International CONDOR Registry.

Stroke 2021 Aug 26:STROKEAHA121034707. Epub 2021 Aug 26.

Department of Neurosurgery, University of Illinois at Chicago, Chicago (M.J.K., A.A., S.A.-H.).

Background And Purpose: Dural arteriovenous fistulae can present with hemorrhage, but there remains a paucity of data regarding subsequent outcomes. We sought to use the CONDOR (Consortium for Dural Arteriovenous Fistula Outcomes Research), a multi-institutional registry, to characterize the morbidity and mortality of dural arteriovenous fistula-related hemorrhage.

Methods: A retrospective review of patients in CONDOR who presented with dural arteriovenous fistula-related hemorrhage was performed. Patient characteristics, clinical follow-up, and radiographic details were analyzed for associations with poor outcome (defined as modified Rankin Scale score ≥3).

Results: The CONDOR dataset yielded 262 patients with incident hemorrhage, with median follow-up of 1.4 years. Poor outcome was observed in 17.0% (95% CI, 12.3%-21.7%) at follow-up, including a 3.6% (95% CI, 1.3%-6.0%) mortality. Age and anticoagulant use were associated with poor outcome on multivariable analysis (odds ratio, 1.04, odds ratio, 5.1 respectively). Subtype of hemorrhage and venous shunting pattern of the lesion did not affect outcome significantly.

Conclusions: Within the CONDOR registry, dural arteriovenous fistula-related hemorrhage was associated with a relatively lower morbidity and mortality than published outcomes from other arterialized cerebrovascular lesions but still at clinically consequential rates.
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http://dx.doi.org/10.1161/STROKEAHA.121.034707DOI Listing
August 2021

Correlation between computed tomography angiography and histology of carotid artery atherosclerosis: Can semi-automated imaging software predict a plaque's composition?

Interv Neuroradiol 2021 Aug 16:15910199211031093. Epub 2021 Aug 16.

Department of Cardiovascular Medicine, 6915Mayo Clinic, USA.

Background: Using computed tomography angiography to differentiate between components of carotid atherosclerotic lesions remains largely elusive. This study sought to validate a semi-automated software for computed tomography angiography plaque analysis using histologic comparisons.

Materials And Methods: A retrospective review was performed of consecutive patients that underwent a carotid endarterectomy, with pre-procedural computed tomography angiography imaging of the cervical arterial vasculature available for review. Images were evaluated using a commercially-available software package, which produced segmented analyses of intraplaque components (e.g. intraplaque hemorrhage, lipid-rich necrotic core, and calcifications). On imaging, each component was assessed in terms of its (1) presence or absence, and (2) both volume and proportion of the total plaque volume (if present). On histological evaluation of carotid endarterectomy specimens, each component was evaluated as an estimated proportion of total plaque volume.

Results: Of 80 included patients, 30 (37.5%) were female. The average age was 69.7 years (SD = 9.1). Based on imaging, intraplaque hemorrhage was the smallest contributor to plaque composition (1.2% of volumes on average). Statistically significant linear associations were noted between the proportion of intraplaque hemorrhage, lipid-rich necrotic core, and calcifications on histology and the volume of each component on imaging ( values ranged from 0.0008 to 0.01). Area under curve were poor for intraplaque hemorrhage and lipid-rich necrotic core (0.59 and 0.61, respectively) and acceptable for calcifications (0.73).

Conclusion: Semi-automated analyses of computed tomography angiography have limited diagnostic accuracy in the detection of intraplaque hemorrhage and lipid-rich necrotic core in carotid artery plaques. However, volumetric imaging measurements of different components corresponded with histologic analysis.
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http://dx.doi.org/10.1177/15910199211031093DOI Listing
August 2021

Venous Causes of Pulsatile Tinnitus: Clinical Presentation, Clinical and Radiographic Evaluation, Pathogenesis, and Endovascular Treatments: A Literature Review.

Neurosurgery 2021 Aug 14. Epub 2021 Aug 14.

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.

Tinnitus is an abnormal perception of a sound without external stimulation. Venous pulsatile tinnitus (VPT) is a specific form of tinnitus characterized by an objective and often subjective bruit that occurs as a result of localized venous abnormalities. Clinical evaluation relies on sound quality, duration, and precipitating factors. Idiopathic intracranial hypertension (IIH) and transverse sinus stenosis (TSS) are among the most common causes of VPT. Other causes include sigmoid sinus wall abnormalities (SSWAs), jugular vein anomalies (JVAs), and emissary veins anomalies. These anomalies can be detected on magnetic resonance imaging, magnetic resonance angiography/magnetic resonance venography, and high-resolution temporal bone computed tomography. The pathogenesis behind the VPT includes turbulent blood flow as a result of luminal stenosis or abnormal dilation, amplification of internal sound due to temporal bone defects, and abnormal position of the venous sinus system structures adjacent to the bony structures of the auditive apparatus. Based on these theories, different interventional treatment modalities can be applied to treat the underlying causes. Endovascular treatments have shown high efficacy and safety among those treatments which include stenting of the lateral sinus stenosis in IIH and TSS, coiling of the SSWA and JVA, and embolization of emissary veins anomalies. Further studies are needed to understand the natural history of these anomalies and the efficacy of treatments of VPT, which-unlike other types of tinnitus-can be cured with proper treatment.
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http://dx.doi.org/10.1093/neuros/nyab299DOI Listing
August 2021

Growth of unruptured aneurysms: A meta-analysis of natural history and endovascular studies.

J Clin Neurosci 2021 Sep 28;91:343-349. Epub 2021 Jul 28.

Department of Neurosurgery, Arkansas Neurosciences Institute, Little Rock AR, USA.

The growth of unruptured intracranial aneurysms (UIAs) is a strong predictor of rupture. Clinical observations suggest that some UIAs might grow faster after endovascular treatment than untreated UIAs. There are no head-to-head comparisons of incidence rates of UIAs thus far.

Methods: We searched PubMed, Embase and Google Scholar for relevant articles from the inception of the databases to March 2020. We pooled and compared the incidence rates for the growth of aneurysms from natural history studies and endovascular treatment studies. Generalized linear models were used for confounder adjustment for the prespecified confounders age, size and location.

Results: Twenty-five studies (10 describing growth in natural history and 15 reporting growth after endovascular therapy) considering 6325 aneurysms were included in the meta-analysis. The median size of aneurysms was 3.7 mm in the natural history studies and 6.4 mm in endovascular treatment studies (p = 0.001). The pooled incidence rate (IR) of growth was significantly higher in endovascular treatment studies (IR 52 per 1000 person-years, with a 95% confidence interval (CI) 36-79) compared to natural history studies (IR 28 per 1000 person-years, 95% CI 17 - 46, p-value < 0.01) after adjustment for confounders.

Conclusion: Our results suggest that the incidence rate of cerebral aneurysm growth might be higher after endovascular therapy than the incidence rates reported in natural history studies. These results should be viewed in light of the risk of bias of the individual studies and the risk of ecological bias.
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http://dx.doi.org/10.1016/j.jocn.2021.07.034DOI Listing
September 2021

Sagittal sinus dural arteriovenous fistula manifesting as unilateral vocal fold paresis.

Clin Neurol Neurosurg 2021 Sep 2;208:106856. Epub 2021 Aug 2.

Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA; Department of Radiology, Mayo Clinic, Rochester, MN, USA.

We present a case of a sagittal sinus dural arteriovenous fistula manifesting as dysphonia secondary to vocal fold paresis. The patient presented with a 6-week history of hoarseness. Imaging studies demonstrated findings suggestive of a dural arteriovenous fistula affecting the superior sagittal sinus. Direct laryngoscopy demonstrated paresis of the right vocal fold. We hypothesized that pressure on the vagus nerve from a dilated and arterialized internal jugular vein within the jugular foramen was responsible for the cranial neuropathy. The patient's dysphonia resolved with embolization of the fistula, and repeat laryngoscopy showed resolution of the vocal fold paresis.
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http://dx.doi.org/10.1016/j.clineuro.2021.106856DOI Listing
September 2021

Elective intervention for unruptured cranial arteriovenous malformations in relation to ARUBA trial: a National Inpatient Sample study.

Acta Neurochir (Wien) 2021 09 21;163(9):2489-2495. Epub 2021 Jul 21.

Department of Radiology, Mayo Clinic, Rochester, MN, USA.

Background: In 2014, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) concluded that medical management alone for cranial arteriovenous malformations (AVMs) had better clinical outcomes than interventional treatment. The impact of the ARUBA study on changes in the rates of intervention and outcomes is unknown. Thus, we investigated whether the conclusions from ARUBA may have influenced treatment modalities and outcomes of unruptured AVMs.

Methods: The National Inpatient Sample (NIS) was queried between 2006 and 2018, for adult patients with an AVM who were admitted on an elective basis. Interventions included open, endovascular, and stereotactic surgeries. Join-point regression was used to assess differences in slopes of treatment rate for each modality before and after the time-point. Logistic regression was used to assess the odds of non-routine discharge and hemorrhage between the two time-points for each treatment modality. Linear regression was used to assess the mean length of stay (LOS) for each treatment modality between the two time-points.

Results: A total of 40,285 elective admissions for AVMs were identified between 2006 and 2018. The rate of intervention was higher pre-ARUBA (n = 15,848; 63.8%) compared to post-ARUBA (n = 6985; 45.2%; difference in slope - 8.24%, p < 0.001). The rate of open surgery decreased, while endovascular and stereotactic surgeries remained the same, after the ARUBA trial time-point (difference in slopes - 8.24%, p < 0.001; - 1.74%, p = 0.055; 0.20%, p = 0.22, respectively). For admissions involving interventions, the odds of non-routine discharge were higher post-ARUBA (OR 1.24; p = 0.043); the odds of hemorrhage were lower post-ARUBA (OR 0.69; p = 0.025). There was no statistical difference in length of stay between the two time-points (p = 0.22).

Conclusion: The rate of intervention decreased, the rate of non-routine discharge increased, and rate of hemorrhage decreased post-ARUBA, suggesting that it may have influenced treatment practices for unruptured AVMs.
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http://dx.doi.org/10.1007/s00701-021-04936-7DOI Listing
September 2021

Endovascular Management of Distal Anterior Cerebral Artery Aneurysms: A Multicenter Retrospective Review.

World Neurosurg 2021 Jul 18. Epub 2021 Jul 18.

Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Introduction: Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA.

Methods: A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0-2). Secondary endpoints included complications and radiographic occlusion at follow-up.

Results: A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access.

Conclusion: Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.
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http://dx.doi.org/10.1016/j.wneu.2021.07.055DOI Listing
July 2021

Endarterectomy for symptomatic non-stenotic carotids: a systematic review and descriptive analysis.

Stroke Vasc Neurol 2021 Jul 8. Epub 2021 Jul 8.

Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA

Objective: To systematically analyse prior reports of carotid endarterectomy (CEA) performed in cases of ≤50% carotid stenosis in order to understand patient tolerance and potential benefit.

Methods: A systematic review and descriptive analysis was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An English-language search was performed of online databases using librarian-selected search terms. Abstracts were reviewed for relevance which included mention of carotid endarterectomy and stenosis. Prospective or retrospective observational cohort studies that reported series of patients who underwent endarterectomy for minimal (≤50%) luminal stenosis with reported outcomes were included.

Results: Six studies (which included our institutional series) with a total of 143 patients met the inclusion criteria. The weighted mean age at the time of CEA was 72.3 years; 113 (79.0%) were male. 55.8% of patients with available data had recurrent ipsilateral ischaemic events despite medical therapy. Two patients out of 129 with available perioperative data (1.6%) had perioperative MRI findings of acute ischaemic stroke, both within the hemisphere contralateral to the side of CEA. Of the 138 patients with available follow-up (mean, 36 months), none had recurrent ipsilateral ischaemic events.

Conclusions: Endarterectomy for symptomatic carotid disease causing ≤50% stenosis may be a potentially beneficial strategy to prevent stroke recurrence. Studies with robust methodology are needed to draw more definitive conclusions in terms of the safety and efficacy of endarterectomy for minimal stenosis with vulnerable features relative to intensive medical therapy.
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http://dx.doi.org/10.1136/svn-2021-001122DOI Listing
July 2021

Repeat Catheter Angiography in Patients with Aneurysmal-Pattern Angiographically Negative Subarachnoid Hemorrhage.

Neurocrit Care 2021 Jun 28. Epub 2021 Jun 28.

Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.

Background: A significant proportion of patients with subarachnoid hemorrhage have a normal cerebral angiogram. Patients with angiographically negative subarachnoid hemorrhage (anSAH) with either perimesencephalic- (panSAH) or aneurysmal-pattern hemorrhage (aanSAH, also known as diffuse anSAH) have an excellent prognosis, but only if underlying vascular abnormalities are completely excluded. The rate of occult aneurysms in patients with aanSAH varies widely across studies. The purpose of this study was to quantify the value of repeat DSA in these patients.

Methods: We reviewed the records of all patients initially diagnosed with aanSAH after a screening DSA at a single tertiary neurovascular referral center from January 2006-April 2018. Patients with panSAH and traumatic SAH were excluded. We also performed a systematic review and meta-analysis of positive second DSAs in previously published case series of patients with aanSAH who underwent two serial DSAs. For meta-analysis, PubMed Central, MEDLINE and Cochrane Library databases were searched for pertinent studies up to November 2019. The rate of aneurysm detection on repeat angiography was extracted from each study. Pooled rates for positive second angiogram were calculated as untransformed proportions in a binary random-effects model meta-analysis. Inter-study heterogeneity was calculated using an I statistic.

Results: Three of 27 patients (11.1%) with aanSAH and at least two DSAs were subsequently found to have a cerebral aneurysm in our institutional dataset. Twenty-six studies in our systematic review met inclusion criteria, and the pooled rate of positive second angiogram was 10.4% (95% CI 7.3%-13.5%, P < 0.001). Substantial inter-study heterogeneity was observed in the meta-analysis (I = 61.7%, P < 0.001).

Conclusions: One in 10 patients with aanSAH has an occult ruptured aneurysm. A second-look DSA should be strongly considered in these cases.
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http://dx.doi.org/10.1007/s12028-021-01247-8DOI Listing
June 2021

Implementation and Rationale for a Unified Clinical and Imaging Protocol for Evaluation and Treatment of Moyamoya Angiopathy: A Single Institutional Experience.

Front Neurol 2021 17;12:662393. Epub 2021 May 17.

Department of Neurology, Mayo Clinic, Rochester, MN, United States.

Moyamoya disease (MMD) is a complex and incompletely-understood cerebrovascular pathological entity that requires thorough clinical and imaging evaluation. Moyamoya is rare, thereby making the establishment of an effective, thorough and interdisciplinary patient evaluation protocol challenging, even within specialized referral centers. Nevertheless, implementation of such a protocol is crucial in order to provide the best possible evaluation and treatment for MMD patients. Here, we describe our institution's implementation of, rationale for, and experience with a comprehensive multidisciplinary collaboration and evaluation strategy for adult patients with moyamoya. This evaluation course consists of, first of all, a thorough clinical and laboratory evaluation with a vascular neurologist. This is followed by a comprehensive imaging assessment which evaluates angiographic and parenchymal features, in addition to cerebrovascular functionality. Finally, appropriate referrals are made to consulting services as indicated, which includes vascular neurosurgery. These steps are described in detail herein.
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http://dx.doi.org/10.3389/fneur.2021.662393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165224PMC
May 2021

Acute thrombosis of a giant perimedullary arteriovenous fistula in a pediatric HHT patient.

Interv Neuroradiol 2021 May 29:15910199211022499. Epub 2021 May 29.

Division of Pediatric Pulmonology, Mayo Clinic, Rochester, MN, USA.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant hereditary disorder that results in arteriovenous malformations (AVMs) in the nose, mucocutaneous surfaces and visceral organs, including lung, brain, liver, bowel and rarely spinal cord. We describe a case of a young child with HHT who presented with acute paraparesis due to acute thrombosis of a spinal perimedullary arteriovenous fistula. Patient underwent coil embolization of spinal arteriovenous shunt with resolution of clinical symptoms. This case highlights the possibility of catastrophic complications in young children with HHT, the potential preventive role of screening for spinal AVMs in HHT and the importance of timely intervention.
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http://dx.doi.org/10.1177/15910199211022499DOI Listing
May 2021

Management of Mobile Thrombus With Distal Protection Devices During Carotid Artery Angioplasty: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Aug;21(3):E242-E243

Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.

Embolic protection devices (EPDs) have become a standard of care during internal carotid artery revascularization.1,2 This video is about a 57-yr-old-male who presented with a wake-up stroke with a left hemispheric syndrome. Head computed tomography angiography (CTA) revealed tandem occlusions of the proximal left internal carotid artery (ICA) and of the distal left middle cerebral artery (MCA) with an ASPECT (Alberta Stroke Program Early CT Score) score of 6. The patient underwent a cerebral angiogram and was treated with balloon angioplasty with a distal EPD and mechanical thrombectomy. The EPD became occluded with thrombus from the ICA and was retrieved through a 6-Fr Sofia (MicroVention) under continuous aspiration. Successful revascularization of the proximal ICA and distal MCA was achieved. No procedure-related complications occurred, and the patient's neurological exam improved. Tandem occlusions can occur in up to 15% of strokes. The optimal treatment can be controversial, but mechanical thrombectomy and ICA revascularization with a distal EPD appear to be safe and effective in selected patients.3 Consent was obtained for the procedure and for the video production.
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http://dx.doi.org/10.1093/ons/opab131DOI Listing
August 2021

Bilateral carotid webs.

Neuroradiol J 2021 May 18:19714009211017783. Epub 2021 May 18.

Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.

Carotid web is thought to be a focal intimal variant of fibromuscular dysplasia, which comprises a high risk of stroke because of blood stasis and subsequent coagulative reactions that occur distal to the web. These lesions generally involve the posterolateral wall of the carotid and their developmental pathogenesis is controversial. This case report describes a 51-year-old woman who presented to the hospital with sudden onset aphasia, right hemi-sensory loss, and right visual field cut. Magnetic resonance imaging (MRI) of the brain demonstrated a left middle cerebral artery (MCA) distribution embolic ischemic infarct with shelf-like linear filling defects in the carotid bulb bilaterally on a computed tomography angiography (CTA) of the head and neck consistent with bilateral carotid webs that were confirmed by catheter angiography. The carotid webs were projecting on the left posteriorly and on the right anteriorly into the inferior aspects of the bilateral proximal internal carotid arteries. The patient was started on clopidogrel and a high-intensity statin and remained on Plavix monotherapy for a 10-month follow up without a recurrent ischemic event.
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http://dx.doi.org/10.1177/19714009211017783DOI Listing
May 2021

Vascular Surgery and Neurosurgery.

Stroke 2021 Jun 7;52(6):2174-2176. Epub 2021 May 7.

Mayo Clinic, Rochester, MN (G.L.).

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http://dx.doi.org/10.1161/STROKEAHA.121.033293DOI Listing
June 2021

Relationship of brainstem infarction to rupture of nonsaccular vertebrobasilar aneurysms.

J Neurosurg 2021 Apr 23:1-7. Epub 2021 Apr 23.

Departments of1Neurosurgery.

Objective: Symptomatic nonsaccular vertebrobasilar aneurysms (NSVBAs) are associated with high rates of aneurysm-related death. Anecdotal evidence suggests that brainstem infarction may be a harbinger of aneurysm rupture. The authors aimed to investigate the association between brainstem infarction and subsequent NSVBA rupture.

Methods: The clinical records and radiographic imaging studies of patients presenting to the authors' institution between 1996 and 2019 for evaluation and management of an NSVBA were retrospectively reviewed to determine the effect of perforating artery infarction on the natural history of NSVBAs. Kaplan-Meier curves for patients with and patients without perforator infarction were constructed, and predictors of aneurysm rupture were identified using a multivariate Cox proportional hazards model.

Results: There were 98 patients with 591.3 person-years of follow-up who met the inclusion criteria for analysis. There were 20 patients who experienced perforator infarction during follow-up. Ten patients (10.2%) experienced aneurysm rupture during follow-up and 26 patients (26.5%) died due to aneurysm-related complications, with annual rates of rupture and aneurysm-related death of 1.7% and 4.4%, respectively. Five patients with a perforator infarction later experienced aneurysm rupture, with a median time between infarction and rupture of 3 months (range 0-35 months). On multivariate analysis, the presence of intraaneurysmal thrombus (risk ratio [RR] 4.01, 95% confidence interval [CI] 1.12-14.44, p = 0.033) and perforator infarction (RR 6.37, 95% CI 1.07-37.95, p = 0.042) were independently associated with risk of aneurysm rupture.

Conclusions: NSVBAs continue to be extremely challenging clinical entities with a poor prognosis. These results suggest that brainstem infarction due to perforating artery occlusion may be a harbinger of near-term aneurysm rupture.
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http://dx.doi.org/10.3171/2020.9.JNS201937DOI Listing
April 2021

Combined Endovascular and Microsurgical Management of Unruptured, Partially Thrombosed, Giant, Internal Carotid Artery Aneurysm: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 07;21(2):E122-E123

Department of Neurologic Surgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.

Giant intracranial aneurysms still represent a serious threat because of high mortality and morbidity and an absence of a widely accepted treatment. Herein, we illustrate the case of a 54-yr-old woman with progressive neurological decline who was found to have an unruptured, giant, partially thrombosed aneurysm of the left supraclinoid portion of internal carotid artery (ICA) with brainstem compression. In this video, we demonstrate the successful stepwise treatment of this lesion with endovascular embolization of the patent portion of the aneurysm, followed by microsurgical debulking and clipping. At 3-yr follow-up, the patient experienced a neurological improvement and performed all normal activity. For patients in which single-modality therapy does not assure a safe treatment option, multimodal management with endovascular and open techniques should be considered as a therapeutic option for complex giant intracranial aneurysms. Consent was given by the patient prior to the surgical procedure. Consent and approval for this operative video, in light of the retrospective nature and use of anonymized material, were waived.
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http://dx.doi.org/10.1093/ons/opab111DOI Listing
July 2021

Letter to the Editor Regarding "Repeated Retching and Vomiting in the Pathophysiology of Isolated Spinal Aneurysms".

World Neurosurg 2021 07 27;151:332-333. Epub 2021 Mar 27.

Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2021.03.096DOI Listing
July 2021

Trends in Utilization of Preoperative Embolization for Spinal Metastases: A Study of the National Inpatient Sample 2005-2017.

Neurointervention 2021 Mar 4;16(1):52-58. Epub 2021 Feb 4.

Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.

Purpose: While previous studies have suggested that preoperative embolization of hypervascular spinal metastases may alleviate intraoperative blood loss and improve resectability, trends and driving factors for choosing this approach have not been extensively explored. Therefore, we evaluated the trends and assessed the factors associated with preoperative embolization utilization for spinal metastatic tumors using a national inpatient database.

Materials And Methods: The National Inpatient Sample database of the Healthcare Cost and Utilization Project was queried for patients undergoing surgical resection for spinal metastasis between January 1, 2005 and December 31, 2017. Patients undergoing preoperative embolization were identified; trends in the utilization of preoperative embolization were analyzed using the Cochran-Armitage test. Multivariable regression was conducted to assess factors associated with higher preoperative embolization utilization.

Results: A total of 11,508 patients with spinal metastasis were identified; 105 (0.91%) underwent preoperative embolization. Of those 105 patients, 79 (75.24%) patients had a primary renal cancer, as compared to 1,732 (15.19%) of those who did not undergo preoperative embolization (P<0.001). The majority of patients in the non-preoperative embolization cohort had a primary lung tumor (n=3,562, 31.24%). Additionally, patient comorbidities were similar among the 2 groups (P>0.05). Trends in preoperative embolization indicated an increase of 0.16% (standard error: 0.024%, P<0.001) in utilization per year.

Conclusion: Utilization of preoperative embolization for spinal metastasis is increasing yearly, especially for patients with renal cancer, suggesting that surgeons may increasingly consider embolization before surgical resection for hypervascular tumors. Additionally, the literature has shown the intraoperative and postoperative benefits of this procedure.
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http://dx.doi.org/10.5469/neuroint.2020.00381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946559PMC
March 2021

Onyx embolization for dural arteriovenous fistulas: a multi-institutional study.

J Neurointerv Surg 2021 Feb 25. Epub 2021 Feb 25.

Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.

Background: Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance.

Objective: To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs.

Methods: From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models.

Results: A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0-129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes.

Conclusions: In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.
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http://dx.doi.org/10.1136/neurintsurg-2020-017109DOI Listing
February 2021

Observation Versus Intervention for Low-Grade Intracranial Dural Arteriovenous Fistulas.

Neurosurgery 2021 05;88(6):1111-1120

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: Low-grade intracranial dural arteriovenous fistulas (dAVF) have a benign natural history in the majority of cases. The benefit from treatment of these lesions is controversial.

Objective: To compare the outcomes of observation versus intervention for low-grade dAVFs.

Methods: We retrospectively reviewed dAVF patients from institutions participating in the CONsortium for Dural arteriovenous fistula Outcomes Research (CONDOR). Patients with low-grade (Borden type I) dAVFs were included and categorized into intervention or observation cohorts. The intervention and observation cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was modified Rankin Scale (mRS) at final follow-up. Secondary outcomes were excellent (mRS 0-1) and good (mRS 0-2) outcomes, symptomatic improvement, mortality, and obliteration at final follow-up.

Results: The intervention and observation cohorts comprised 230 and 125 patients, respectively. We found no differences in primary or secondary outcomes between the 2 unmatched cohorts at last follow-up (mean duration 36 mo), except obliteration rate was higher in the intervention cohort (78.5% vs 24.1%, P < .001). The matched intervention and observation cohorts each comprised 78 patients. We also found no differences in primary or secondary outcomes between the matched cohorts except obliteration was also more likely in the matched intervention cohort (P < .001). Procedural complication rates in the unmatched and matched intervention cohorts were 15.4% and 19.2%, respectively.

Conclusion: Intervention for low-grade intracranial dAVFs achieves superior obliteration rates compared to conservative management, but it fails to improve neurological or functional outcomes. Our findings do not support the routine treatment of low-grade dAVFs.
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http://dx.doi.org/10.1093/neuros/nyab024DOI Listing
May 2021

The Role of Angioplasty Alone in Intracranial Atherosclerosis: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 04;20(5):E350-E351

Department of Radiology, Mayo Clinic, Rochester, Minnesota.

Intracranial atherosclerosis disease (IAD) is the cause of stroke in up to 10% of cases. Symptomatic IAD results mainly from hypoperfusion, embolic phenomenon, and occlusion. Treatment consists of conservative management with aggressive medical treatment, surgery, and endovascular therapy.1,2 This video is about a 62-yr-old male who presented with left-sided hemiparesis and right gaze preference secondary to an acute ischemic stroke in the right middle cerebral artery (MCA) territory treated initially with  tissue plasminogen activator (tPA). Head computed tomography (CT) angiography (CTA) revealed occlusion of the extracranial and cavernous segments of the internal carotid artery (ICA). CT perfusion (CTP) showed hypoperfusion in the MCA territory and magnetic resonance imaging (MRI) revealed multifocal, wedge-shaped areas of restricted diffusion in the right hemisphere. During his hospitalization, he experienced worsening of his symptoms in the setting of hypoperfusion (hypotension). The patient underwent a cerebral angiogram with thrombectomy and submaximal angioplasty (SA). Successful revascularization of the right ICA was obtained. No procedure-related complications occurred, and the patient's neurological exam improved. SA can be as efficient and a safer option than conventional angioplasty or angioplasty and stenting for symptomatic IAD. The patient consented for the procedure and for the video production.
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http://dx.doi.org/10.1093/ons/opaa479DOI Listing
April 2021

Long-term clinical and mid-term radiographic follow-up of pure arterial malformations.

Acta Neurochir (Wien) 2021 04 10;163(4):1181-1189. Epub 2021 Feb 10.

Department of Neurosurgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Background: Pure arterial malformations (PAMs) are rare vascular lesions characterized by dilated, tortuous arterial loops without venous shunting. The natural history of PAMs remains unclear. We report the mid-term radiological and longer-term clinical outcomes of the largest series of patients with PAM.

Methods: Retrospective review at a tertiary academic referral center for patients with a PAM. Follow-up clinical and radiological data were collected and analyzed for clinical symptoms and radiographic changes.

Results: Twenty-five patients met the inclusion criteria. The mean age at presentation was 30.9 ± 14 years. Nineteen (76%) patients were female, and six (23.1%) were male. Eleven (44%) patients had ≥1 symptom at presentation, of which only 3 (12%) could be linked to PAM. The most common symptom was headache (n=8). PAMs involved a single vessel in 16 (64%) cases and ≥2 vessels in 9 cases (36%). Fifteen (60%) lesions were isolated to the anterior circulation compared to 6 (24%) in the posterior circulation. The most frequently involved vessel was the supraclinoid internal cerebral artery (36%). An associated saccular aneurysm was present in 32% of patients. Ten lesions were partially calcified. The mean radiographic and clinical follow-up was 21.9 ± 26.5 months and 44.6 ± 34.8 months, respectively. None of the patients developed new symptoms related to their lesion or radiographic progression over the duration of follow-up.

Conclusions: PAMs are found most frequently in young, asymptomatic females. PAMs have a benign natural history and are best managed conservatively with serial imaging.
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http://dx.doi.org/10.1007/s00701-021-04736-zDOI Listing
April 2021

Semiautomated carotid artery plaque composition: are intraplaque CT imaging features associated with cardiovascular risk factors?

Neuroradiology 2021 Feb 5. Epub 2021 Feb 5.

Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.

Background: Little remains known about the connection between cardiovascular (CV) risk factors and carotid plaque morphologies. This study set out to assess for any such associations.

Materials And Methods: A retrospective review was completed of consecutive patients that had CTA neck imaging prior to CEA. Body mass index (BMI), tobacco and/or alcohol use, and history of diabetes and/or hypertension were collected from patients' medical records. Lab values were dichotomized based on values: total cholesterol < 200 or ≥ 200; low-density lipoprotein (LDL) < 130 or ≥ 130, high-density lipoprotein < 35 or ≥ 35, and triglycerides < 200 or ≥ 200. A semiautomated analysis of CTA images computed maximum stenosis, intraplaque volumes of intraplaque hemorrhage, lipid-rich necrotic core (LRNC), and matrix, and intraplaque volume and proportional plaque makeup of calcifications of each carotid plaque.

Results: Of 87 included patients, 54 (62.1%) were male. Mean age was 70.1 years old. Both diabetes and hypertension were associated with greater intraplaque calcification volume (p = 0.0009 and p = 0.01, respectively), and greater proportion of calcification within a plaque (p = 0.004 and p = 0.01, respectively). Higher BMI was associated with greater intraplaque volume of LRNC (p=0.02) and matrix (0.0007). Elevated total cholesterol was associated with both larger intraplaque calcification volume (p = 0.04) and greater proportion of calcification within a plaque (p = 0.01); elevated LDL was associated with greater intraplaque calcification volume (p = 0.005).

Conclusion: Multiple CV risk factors are associated with morphological differences in carotid artery plaques. Dysregulation of both total cholesterol and LDL and higher BMI are associated with higher volumes of intraplaque LRNC, a marker of plaque vulnerability.
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http://dx.doi.org/10.1007/s00234-021-02662-6DOI Listing
February 2021
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