Marc A. Lazzaro

Moyamoya syndrome is a rare cerebrovascular disorder characterized by progressive occlusion of the supraclinoid internal carotid artery and proximal portions of the anterior and middle cerebral arteries resulting in an extensive network of collateralized blood vessels and producing a characteristic angiographic appearance. Although the pathophysiology is unclear, hematologic disorders have been associated with development of the moyamoya syndrome. A case report is presented. A 29 year-old female with a history of essential thrombocythemia developed progressive ischemic strokes. Angiography revealed characteristic moyamoya changes and pathologic examination showed intimal hyperplasia with scant collagen fibers and myxoid change. This is the first reported case of moyamoya syndrome in an adult patient with essential thrombocythemia demonstrating histological findings that suggest a shared pathophysiology with moyamoya syndrome in sickle cell anemia.

Introduction: The threatened vascular territory in ischemic stroke is maintained by pial collateral circulation. Neovascularization varies among organ systems in diabetic patients. The effect of diabetes on the extent of pial collaterals is not well known. The pial collateral supply was compared among diabetic and non-diabetic patients presenting with acute ischemic stroke.Material and methods: Databases from two institutions were accessed to identify all patients who presented with acute middle cerebral artery occlusion and underwent emergent cerebral angiography. Angiograms were reviewed and graded using a previously published pial collateral grading system. The collateral grading system was dichotomized into good (pial grades 1–2) and poor (pial grades 3–5). A χ²analysis was performed to compare the association between diabetes and pial collateral grade.Results: 104 patients were identified; 56 (54%) patients were men, mean age was 63.5 years and 22 (21%) patients had diabetes. Mean admission National Institutes of Health Stroke Scale was 15.7. In the diabetic population, 15 (68.2%) patients had good pial collaterals while seven (31.8%) patients had poor pial collaterals. In the non-diabetic population, 59 (71.9%) patients had good pial collaterals while 23 (28.0%) patients had poor pial collaterals. There was no association between diabetes and pial collateral grade (p=0.7290, Pearson χ²).Conclusions: This series suggests there is no association between diabetes and the extent of pial collaterals in ischemic stroke patients. Further studies are warranted to understand pial collateral patterns in acute ischemic stroke patients and their impact on clinical outcomes.

Endovascular tumor embolization as adjunctive therapy for head and neck cancers is evolving and has become an important part of the tools available for their treatment. Careful study of tumor vascular anatomy and adhering to general principles of intra-arterial therapy can prove this approach to be effective and safe. Various embolic materials are available and can be suited for a given tumor and its vascular supply. This article aims to summarize current methods and agents used in endovascular head and neck tumor embolization and discuss important angiographic and treatment characteristics of selected common head and neck tumors.

Introduction: Techniques for coil embolization of wide-neck cerebral aneurysms include the use of stents and temporary occlusion with compliant non-detachable balloons to safely allow dense packing of the aneurysm lumen with detachable coils. We describe the use of a new balloon device for assisting in wide-neck aneurysm coil treatment. Methods: A single institution neuroendovascular database was accessed to identify cases in which the Ascent balloon (Codman Neurovascular, Raynham, MA, USA) was used for aneurysm coil embolization. Clinical, demographic, and angiographic data were obtained through chart review. Results: Eleven cerebral aneurysm cases were treated using the Ascent balloon during the first 12-month period that the new device was available at our institution. Three of the patients presented with ruptured aneurysms. All aneurysms were large (maximum diameter 6 mm or greater), with an average maximum diameter of 9.4 mm, and an average neck diameter of 5.5 mm. Complete occlusion with coil embolization (Raymond class I) was achieved in all cases. The Ascent balloon was successfully positioned across the neck of the aneurysm in nine patients. Conclusion: This initial experience demonstrates the feasibility and immediate outcomes of the coaxial dual-lumen design Ascent balloon catheter used as an assistive device in coil embolization of wide-neck cerebral aneurysms. This device contributes to the growing number of assistive devices for the treatment of complex cerebral aneurysms.

Recent reports have emerged suggesting that multiple sclerosis (MS) may be due to abnormal venous outflow from the central nervous system, termed chronic cerebrospinal venous insufficiency (CCSVI). These reports have generated strong interest and controversy over the prospect of a treatable cause of this chronic debilitating disease. This review aims to describe the proposed association between CCSVI and MS, summarize the current data, and discuss the role of endovascular therapy and the need for rigorous randomized clinical trials to evaluate this association and treatment.

Background: The dissecting posterior cerebral artery (PCA) aneurysms are very rare. These aneurysms pose significant treatment challenge and need careful evaluation to formulate an optimal treatment plan in case of ruptured or un-ruptured presentations. Methods: Retrospective review of a prospectively collected data. Results: Seven patients with dissecting aneurysms of the PCA were identified. Six out of seven presented with subarachnoid hemorrhage (SAH) and one with ischemic stroke. Three out of seven were treated with endovascular coil embolization without sacrifice of the parent artery and the rest had parent artery occlusion (PAO) with coil embolization. None of the patients developed new neurological deficits post-procedure. Aneurysm re-occurred in two patients that were treated without PAO. Conclusion: Endovascular treatment of the dissecting PCA aneurysm is safe and feasible. It can be performed with or without PAO. Recurrence is more common without PAO and close follow-up is warranted.

Antithrombotic therapy plays a key role in secondary ischemic stroke prevention. A multitude of antithrombotic agents exist with varying pharmacologic, efficacy, and safety profiles. In this review, the authors discuss the mechanisms of antithrombotic therapy, summarize the data on commonly used agents, and introduce emerging antithrombotic medications.

Induced hypothermia is a promising neuroprotective treatment for acute ischemic stroke. Data from both global and focal ischemia animal models have been encouraging. However, only a few small clinical studies have investigated its use in humans. To review the background, possible mechanisms of action, and the preclinical and clinical data supporting the neuroprotective role of induced hypothermia following acute ischemic stroke. A literature search was performed using the PubMed database. Only papers in English were reviewed. Induced hypothermia is effective as a neuroprotectant in animal models of acute ischemic stroke. Its multimodal mechanism of action makes it a very attractive method of neuroprotection. Although human studies suggest it is safe and feasible, larger randomized controlled trials are necessary to address clinical efficacy and to refine the methods and parameters of induced hypothermia protocols.