Journal of neurointerventional surgery
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Case Reports
De novo development of dural arteriovenous fistula after endovascular embolization of pial arteriovenous fistula.
The development of de novo dural arteriovenous fistula(s) following endovascular embolization of a prior high-flow pial arteriovenous fistula (PAVF) has not previously been reported and the natural history is unknown. The anatomic basis, pathophysiologic mechanism, management and outcome are discussed. ⋯ De novo dural fistulas following endovascular embolization of high-flow PAVFs is not an uncommon development. They are mostly asymptomatic and develop anywhere along the drainage of the fistula, maturing over time and diagnosed during follow-up studies, emphasizing the need for follow-up angiography. They can be effectively treated by endovascular embolization. Localized refractory dural fistulas can be dealt with by radiosurgery.
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There is a growing body of literature supporting venous sinus stenosis as a causative etiology for many patients diagnosed with idiopathic intracranial hypertension. Recent series have documented improvement in the pre- and post-stenosis venous pressure gradient as well as clinical symptoms after stenting. Concomitant real time intracranial pressure (ICP) monitoring has not been previously described during venous sinus stenting. ⋯ A case is presented of severe intracranial hypertension with rapidly progressive neurologic decline despite CSF diversion secondary to venous sinus stenosis that resolved following venous sinus stenting. This is the first report of real time ICP monitoring during venous sinus stenting.
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The success of mechanical clot retrieval for acute ischemic stroke may be influenced by the characteristics of the occlusive thrombus. The thrombus can be partly characterized by CT, as the hyperdense vessel sign (HVS) suggests erythrocyte-rich clot whereas fibrin-rich clot may be isodense. We hypothesized that the physical clot characteristics that determine CT density may also determine likelihood of retrieval with the Merci device. ⋯ The HVS in acute ischemic stroke was strongly predictive of successful recanalization using the Merci device. The HVS may indicate thrombi that are less adhesive compared with isodense clots that are more resistant to mechanical retrieval. The absence of HVS on pre-treatment CT may thus suggest the need for a more aggressive or alternative therapeutic approach.
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Federal healthcare spending has been a subject of intense concern as the US Congress continues to search for ways to reduce the budget deficit. The Congressional Budget Office (CBO) estimated that, even though it is growing more slowly than previously projected, federal spending on Medicare, Medicaid and the State Children's Health Insurance Program (SCHIP) will reach nearly $900 billion in 2013. In 2011 the Medicare program paid $68 billion for physicians and other health professional services, 12% of total Medicare spending. ⋯ This review explores the historical development of the SGR, touches on elements of the formula itself and outlines current proposals for fixing the SGR problem. A recent CBO estimate reduces the potential cost of a 10-year fix of SGR system to $138 billion. This has provided new hope for resolution of this long-standing issue.
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Large and giant aneurysms pose significant challenges to the endovascular techniques of coil embolization or parent vessel reconstruction. Many large aneurysms are wide-necked with bulbous domes and frequently require stent-assisted coiling or flow diversion to reconstruct and preserve flow through the parent artery. ⋯ The stent anchor technique, a novel method of obtaining distal purchase that allows straightening of the catheter loop within a large aneurysm for the purposes of stenting for vessel reconstruction across large or giant aneurysms, is presented. This technique may facilitate the use of new stent technologies in the treatment of large aneurysms that have traditionally been exceedingly difficult to treat via an endovascular approach.