Editor’s Choices

The Influence of Carotid Artery Catheterization Technique on the Incidence of Thromboembolism during Carotid Artery Stenting • H.J. Kim, H.J. Lee, J.H. Yang, I.S. Yeo, J.S. Yi, I.W. Lee, S.B. Lee, S.Y. Ryu, J.K. Kim, and P.S. Yang
The risk of stroke is one of the main concerns when performing carotid artery stenting and has prevented this technique from becoming widely accepted. Here, the authors used diffusion-weighted imaging to evaluate 32 consecutive patients who underwent CAS with 2 different catheterization techniques: one with a 7F or 8F catheter and the other with a coaxial system (same size) in conjunction with a 4F or 5F catheter. Post-CAS infarcts were found in 53% of patients and were significantly more common in those older than 65 years. All infarcts were asymptomatic and the incidence in the territory of the treated artery was similar for both techniques. Infarcts outside the territory of the treated artery were significantly higher in the first group. Conclusion: infarctions in other territories mainly arise from the atherosclerotic aortic arch and arch vessels during the manipulation of endoluminal devices. The catheterization technique using the coaxial system with a 7F or 8F catheter in conjunction with a 4F or 5F catheter reduced the incidence of new embolic signal in other territories.

Cost-Effectiveness of CT Perfusion for Selecting Patients for Intravenous Thrombolysis: A US Hospital Perspective • D. Jackson, S.R. Earnshaw, R. Farkouh,and L. Schwamm
If patients were selected for intravenous tissue plasminogen activator based on the presence of a penumbra (as seen on perfusion studies), perhaps their outcome could be improved. These authors assumed “limited availability of MR imaging in hospital” and thus decided to use CT for this study. They analyzed costs and outcomes associated with penumbra-based CT perfusion selection of patients. They concluded that using penumbra-based CTP after routine CT to select patients with ischemic stroke for IV tPA is cost-effective compared with the usual CT-based methods. With the ease of access to CTP, penumbra-based selection methods may be readily available to hospitals. Thus, this economic analysis may lend further support to the consideration of a paradigm shift in acute stroke evaluation.

Practical Scoring System for the Identification of Patients with Intracerebral Hemorrhage at Highest Risk of Harboring an Underlying Vascular Etiology: The Secondary Intracerebral Hemorrhage Score • J.E. Delgado Almandoz, P.W. Schaefer, J.N. Goldstein, J. Rosand, M.H. Lev, R.G. González, and J.M. Romero
From the same institution as the previous study comes this one, which aimed to develop a practical scoring scheme to stratify patients with brain hemorrhage according to their risk of harboring an underlying vascular etiology (aneurysm, arteriovenous malformation, etc). The authors retrospectively reviewed 623 patients who underwent CT angiography, developed a scoring system based on them, and then applied it to 222 new patients who came to the emergency department. Patients with typical basal cistern subarachnoid hemorrhage were excluded. Vascular lesions were found in 120/845 patients, the most common being aneurysm with purely intracerebral rupture. The scoring system successfully predicted a given patient with intracerebral hemorrhage’s risk of harboring an underlying vascular etiology and could be used as a guide to select patients with ICH for neurovascular evaluation to exclude the presence of a vascular abnormality.

Fellows’ Journal Club

Klippel-Trenaunay Syndrome and Spinal Arteriovenous Malformations: An Erroneous Association • A.I. Alomari, D.B. Orbach, J.B. Mulliken, A. Bisdorff, S.J. Fishman, A. Norbash, R. Alokaili, D.J. Lord, and P.E. Burrows
This article represents good use of existing literature to shed light on the manifestations of an uncommon disease. The authors searched MEDLINE and reviewed books to assess the relationship of Klippel-Trenaunay syndrome and spinal arteriovenous malformations. In addition, they searched their own data base for KTS cases and looked for this association. They found 24 reports of spinal AVMs in 31 KTS patients. It seems that the diagnosis of KTS was not well established in any of these patients. In their own database, they found 208 KTS patients and none had AVMs. Thus, the known association between AVMs and KTS is most likely erroneous.

Clinical and Radiological Features of Rotavirus Cerebellitis • J. Takanashi, T. Miyamoto, N. Ando, T. Kubota, M. Oka, Z. Kato, S. Hamano, S. Hirabayashi, M. Kikuchi, and A.J. Barkovich
I chose this article because I find that viral cerebellitis is often included in the differential diagnosis of nonspecific T2 changes in the cerebellum. Here, the authors retrospectively analyzed MR imaging, clinical, and laboratory data in patients with rotavirus cerebellitis treated in several Japanese hospitals. Eleven of 13 patients had supratentorial findings in addition to the cerebellitis, and clinically nearly all developed mutism early in the course of the disease in addition to typical cerebellar abnormalities such as dysarthria, ataxia, dysmetria, etc. The most common sites of abnormalities were the vermis and cerebellar cortex along with a reversible splenial lesion. Some cerebellar lesions were also transient and nearly all patients showed cerebellar atrophy in the chronic stage.

The Risk of Acute Radiocontrast-Mediated Kidney Injury Following Endovascular Therapy for Acute Ischemic Stroke Is Low • Y. Loh, D.L. McArthur, P. Vespa, Z.-S. Shi, D.S. Liebeskind, R. Jahan, N.R. Gonzalez, S. Starkman, J.L. Saver, S. Tateshima, G.R. Duckwiler, and F. Viñuela
When performing endovascular recanalization in patients with acute stroke, one may use significant amounts of iodinated contrast material. These authors assessed the risk of contrast-induced nephropathy after this type of treatment. Ninety-nine patients with acute stroke were treated and their kidney function was assessed before the procedure and 48 hours later. The average amount of contrast used was about 190 mL. Three patients developed nephropathy that resolved before all died from the stroke. Higher morbidity rates were present in the usual suspects: patients with diabetes, chronic renal disease, higher creatinine levels on admission, etc. Conclusion: the risk of contrast-induced nephropathy of endovascular stroke recanalization is very low, but larger studies are needed to confirm this finding.