Exploring the Ethical Landscape of Pediatric Neuroendovascular Treatments.

The treatment of neurovascular disease in children continues to push clinical and innovative boundaries, carrying with them uniquely high stakes. Hemorrhage from, or occlusion of, a major cerebral blood vessel may result in devastating neurological injury or death. In children and young people, the stakes around a decision to offer or withhold treatment are even greater.

Thrombectomy Versus Medical Management for Pediatric Arterial Ischemic Stroke With Large Baseline Infarct.

Background: Multiple recent randomized trials have demonstrated the benefit of thrombectomy over medical management alone in adult patients with large vessel occlusion (LVO) stroke and large infarct on baseline imaging. Cohort studies have also identified improved functional outcomes in pediatric patients who received thrombectomy. However, the role of thrombectomy in pediatric stroke with large baseline infarct remains uncertain.

Recommendations from the International Paediatric Stroke Organization on pediatric neurointerventional best practices based on Delphi consensus.

Paediatric neurointervention (PNI) markedly differs from adult neuro-intervention, requiring highly subspecialized clinical skills, knowledge, and techniques. Minimum standards of practice are well established in adult neurointervention but are lacking in the field of PNI. We sought to develop expert consensus on best practices for neurointervention in children.

Identification of a T2-hyperintense Perivascular Space in Brain Arteriovenous Malformations.

Background/aim: Brain arteriovenous malformations (AVMs) are vascular malformations characterized by dysmorphic, aberrant vasculature. During previous surgeries of compact nidus brain AVMs (representing the majority of cases), we have observed a "shiny" plane between nidal and perinidal AVM vessels and the surrounding grey and white matter and hypothesized that preoperative neuroimaging of brain AVMs may show a neuroradiological correlate of these intraoperative observations.

Patients And Methods: We retrospectively reviewed and analyzed multiplanar and multisequence 3-Tesla magnetic resonance (3T MR) imaging in five consecutive brain AVMs with special attention on imaging characteristics of the brain-AVM interface, i.

Intracranial Arterial Aneurysms in Childhood.

Intracranial arterial aneurysms in children are rare. They differ from adult aneurysms in their etiology, natural history, and management approach. Unruptured asymptomatic aneurysms in children can often be observed for growth over time.

Mechanical Thrombectomy for Pediatric Arterial Ischemic Stroke from Acute M2 Occlusion.

Pediatric large-vessel occlusion has a poor natural history. Recent retrospective studies have demonstrated the potential benefits, feasibility, and safety profile of mechanical thrombectomy in children. However, the role of thrombectomy in pediatric M2 occlusions remains uncertain.

Association Between Thrombectomy and Functional Outcomes in Pediatric Patients With Acute Ischemic Stroke From Large Vessel Occlusion.

Importance: Pediatric large vessel occlusion (LVO) stroke has a poor natural history. However, uptake of mechanical thrombectomy is hindered by a lack of clinical trial data in children. A randomized clinical trial is not feasible due to small sample sizes and absence of equipoise.

Incidence and Natural History of Pediatric Large Vessel Occlusion Stroke: A Population Study.

Importance: The incidence and natural history of large vessel occlusion (LVO) stroke in children is largely unknown. These knowledge gaps limit the uptake of reperfusion therapies and reduce the efficiency of pediatric acute stroke pathways.

Objective: To determine the incidence and natural history of pediatric LVO stroke.

Current Concepts in Intracranial Interstitial Fluid Transport and the Glymphatic System: Part II-Imaging Techniques and Clinical Applications.

The glymphatic system is a recently discovered network unique to the central nervous system that allows for dynamic exchange of interstitial fluid (ISF) and cerebrospinal fluid (CSF). As detailed in part I, ISF and CSF transport along paravascular channels of the penetrating arteries and possibly veins allow essential clearance of neurotoxic solutes from the interstitium to the CSF efflux pathways. Imaging tests to investigate this neurophysiologic function, although challenging, are being developed and are reviewed herein.

Current Concepts in Intracranial Interstitial Fluid Transport and the Glymphatic System: Part I-Anatomy and Physiology.

Normal physiologic function of organs requires a circulation of interstitial fluid to deliver nutrients and clear cellular waste products. Lymphatic vessels serve as collectors of this fluid in most organs; however, these vessels are absent in the central nervous system. How the central nervous system maintains tight control of extracellular conditions has been a fundamental question in neuroscience until recent discovery of the glial-lymphatic, or glymphatic, system was made this past decade.

Symptomatic Unruptured Arteriovenous Malformations: Focal Edema, Thrombosis, and Vessel Wall Enhancement: A Retrospective Cohort Study.

Background: Focal brain edema in unruptured brain arteriovenous malformations (AVMs) is rare and associated with venous outflow abnormalities and aneurysm growth. These patients have an increased rate of progressive neurologic symptoms, as well as a potentially increased risk of hemorrhage. In this study, we aim to assess in further detail the relationship between perifocal edema and enhancement of the vessel wall in symptomatic patients with an unruptured brain AVM.

Cavernous sinus embolisation prior to removal of penetrating foreign body in a 6-year-old child.

Transorbital penetrating foreign bodies are extremely rare in children and may penetrate the cavernous sinus or the underlying internal carotid artery. Parent vessel sacrifice and temporary balloon occlusion are feasible options for managing arterial injury during removal of the foreign body. Even in the absence of arterial injury, the ophthalmologist may encounter significant bleeding from the cavernous sinus deep in their operative field that is difficult to control.

Deep venous communication in vein of Galen malformations: incidence, Imaging, and Implications for treatment.

Background: Failure to appreciate deep venous drainage pathways is a major cause of severe complications in the endovascular treatment of vein of Galen aneurysmal malformations (VOGMs).

Objective: To report deep venous drainage patterns in patients with VOGM, emphasizing the internal cerebral veins, and to describe the challenges in evaluating these.

Methods: Patients with VOGM presenting to our institute between 2000 and 2018 were retrospectively analyzed.

First clinical experience with the new Surpass Evolve flow diverter: technical and clinical considerations.

Objective: To describe the results in patients treated with the Surpass Evolve (SE) device, the new generation of Surpass flow diverters.

Methods: Twenty-five consecutive patients (20 women, average age 58 years), with anterior or posterior circulation aneurysms treated with SEs in two early-user centers, were included. Device properties and related technical properties, imaging and clinical follow-up data, and intraprocedural, early (<30 days) and delayed (>30 days) neurological complications, further divided into minor (silent/non-permanent) and major (permanent) complications, were recorded and analyzed.

Procedural success with radial access for carotid artery stenting: systematic review and meta-analysis.

Background: Femoral access is the traditional approach for endovascular carotid artery stenting. Radial access is increasingly used as an alternative approach due to its known anatomical advantages in patients with unfavorable aortic arch morphology via the femoral approach and its excellent access site safety profile. Our objective was to analyze procedural success using radial access for carotid artery stenting as reported in the literature.

Periprocedural complications of second-generation flow diverter treatment using Pipeline Flex for unruptured intracranial aneurysms: a systematic review and meta-analysis.

Background: Flow diverters are a breakthrough treatment for large and giant intracranial aneurysms but carry a risk of periprocedural death or major stroke. Pipeline Flex is a second-generation device that is thought to have lower complication rates because of improvements in the delivery system as well as increased operator experience. Our objective was to analyze the risk of periprocedural death or major complications using Pipeline Flex for unruptured intracranial aneurysms.

Subcaudate Tractotomy White Matter Anatomy and Variability: A Diffusion Tensor Imaging Study.

Background: Subcaudate tractotomy is a functional ablative procedure performed for treatment-resistant psychiatric disease, targeting the white matter tracts ventral to the head of the caudate nucleus. The white matter anatomy of this region has extensive interindividual variability, and this is thought to impact upon the treatment response to ablative and deep brain stimulation procedures.

Objective: We aim to assess in detail the white matter tract anatomy and topographic variability underlying subcaudate tractotomy.

Reduced integrity of the uncinate fasciculus and cingulum in depression: A stem-by-stem analysis.

Introduction: The subgenual cingulate gyrus (Brodmann's Area 25: BA25) is hypermetabolic in depression and has been targeted successfully with deep brain stimulation. Two of the white matter tracts that play a role in treatment response are the uncinate fasciculus (UF) and the cingulum bundle. The UF has three prefrontal stems, the most medial of which extends from BA25 (which deals with mood regulation) and the most lateral of which extends from the dorso-lateral prefrontal cortex (concerned with executive function).

SPECT-CT/VQ versus CTPA for diagnosing pulmonary embolus and other lung pathology: Pre-existing lung disease should not be a contraindication.

Introduction: Single Photon Emission Computed Tomography-Ventilation-Perfusion (SPECT-VQ) with low-dose CT (SPECT-CT/VQ) has equivalent diagnostic accuracy to CTPA for diagnosing pulmonary embolus (PE) while using lower radiation doses, but is underutilized owing to perceived inaccuracy of scintigraphy in the setting of pre-existing lung disease. This study assesses the accuracy of SPECT-CT/VQ compared with CTPA for the diagnosis of PE, including in patients with pre-existing lung disease.

Methods: Retrospective non-inferiority cohort study of all patients who underwent SPECT-CT/VQ scanning at St Vincent's Hospital, NSW, from June 2012 to November 2013, who also had a CTPA within the same admission and <72 h apart (n = 102).

Diffusion tensor imaging to aid subgenual cingulum target selection for deep brain stimulation in depression.

Background: The most investigated target for deep brain stimulation in depression is the subgenual cingulate gyrus (Cg25) which has been shown to be a critical hub for signalling in the condition. Diffusion tensor imaging (DTI) is a form of MR sequence that can visualise white matter connections and potentially aid target selection.

Objectives: To assess whether targets selected using DTI to find the area of maximal tract crossover (maximal isotropy) underlying the subgenual cingulum differ significantly in location from those selected using standard T(2) sequences.

Successful treatment of six cases of indirect carotid-cavernous fistula with ethylene vinyl alcohol copolymer (Onyx) transvenous embolization.

Background: Endovascular transvenous treatments have become the mainstay in the management of indirect carotid-cavernous fistulas (CCFs). However, the standard coil techniques are associated with a substantial failure and complication rate. The ethylene vinyl alcohol copolymer (Onyx) Liquid Embolization System has advantages over coils, including the ability to penetrate and occlude vessels of small caliber or with difficult access.

How rapidly does cerebral swelling follow trauma? Observations using an animal model and possible implications in infancy.

To study the speed of development of cerebral edema in an animal model, five 2-year-old male anesthetized Merino sheep were impacted in the left temporal region by a humane stunner. Following the induction of blunt craniocerebral trauma a highly significant increase in intracranial pressure (ICP) values occurred relative to control animals (ANOVA, p<0.001).