Monash Health

Endovascular treatment of a hepatic artery pseudoaneurym using a novel pericardium covered stent

Sun, 13 Oct 2019 00:00:00 GMT

Title: Endovascular treatment of a hepatic artery pseudoaneurym using a novel pericardium covered stent Authors: Larner B.; Maingard J.; Ren Y.; Kok H.K.; Chandra R.V.; Lee M.J.; Schelleman A.; Brooks D.M.; Asadi H. Abstract: Visceral and renal artery aneurysms (VRAAs) and pseudoaneurysms are rare. Their increasing incidence is largely thought to be due to advances in medical imaging. Twenty percent of VRAAs occur in hepatic arteries, with approximately fifty percent of these represented by pseudoaneurysms, which are prone to spontaneous rupture. Many treatments for VRAAs exist, with the endovascular approach being favoured. Treatment aims to preserve visceral perfusion and exclude the aneurysm; however, complex aneurysms may require parent artery or end-organ sacrifice. Covered stents allow rapid aneurysm exclusion while preserving parent artery patency, a favourable outcome when parent artery or end-organ sacrifice is undesirable. The AneuGraft pericardium covered stent (PCS) combines the benefits of a low-profile covered stent with those of a low immunogenic material. We describe the endovascular treatment of a patient with a hepatic artery pseudoaneurysm, where parent artery sacrifice was considered unacceptable. The AneuGraft PCS was used to provide immediate and complete exclusion, with dual antiplatelet therapy for 1 week, followed by single antiplatelet use. The procedure was a technical success, with preservation of the hepatic arteries and complete exclusion of the pseudoaneurysm. There were no complications immediately following the procedure or on post-procedural follow-up. The pseudoaneurysm remained excluded at 6-week CT angiogram (CTA) follow-up. This case describes a safe and effective method for completely excluding a complex pseudoaneurysm, utilising the AneuGraft PCS, allowing for the potential management of a wider range of aneurysms with unfavourable morphology.

Reversible corona radiata diffusion restriction in hypoglycemic coma

Thu, 01 Jan 2015 00:00:00 GMT

Title: Reversible corona radiata diffusion restriction in hypoglycemic coma Authors: Slater L.; Stuckey S.L.; Thyagarajan D.; Chandra R.V. Abstract: Thirty-four hours after last being seen well, a 45-year-old diabetic woman was discovered in profound hypoglycemic coma. Magnetic resonance imaging (MRI) revealed bilateral symmetrical corona radiata signal abnormality with diffusion restriction (Figure 1A-C). Electroencephalogram revealed diffuse slowing. Overall, a poor clinical outcome was predicted. However, with rapid establishment of euglycemia and supportive care, the patient slowly recovered over the next 4 weeks. Repeat MRI showed reversal of all neuroimaging findings (Figure 1D-F). By 3 months, she was discharged home with a modified Rankin scale score of 1.

Greater clinical impact of thrombectomy compared to thrombolysis in first year of Melbourne Mobile Stroke Unit operation

Wed, 12 Feb 2020 00:00:00 GMT

Title: Greater clinical impact of thrombectomy compared to thrombolysis in first year of Melbourne Mobile Stroke Unit operation Authors: Zhao H.; Coote S.; Easton D.; Langenberg F.; Stephenson M.; Smith K.; Bernard S.; Kim J.; Cadilhac D.; Churilov L.; Brooks M.; Asadi H.; Thijs V.; Chandra R.; Ma H.; Desmond P.M.; Mitchell P.J.; Yassi N.; Yan B.; Campbell B.C.; Parsons M.W.; Donnan G.A.; Davis S.M. Abstract: Introduction: The role of mobile stroke units (MSU) in earlier provision of thrombolysis (tPA) is well described, but the effect on endovascular thrombectomy (EVT) is less clear. Despite the theoretical advantages of improved triage and prehospital activation of EVT services, only a small effect on hospital arrival to EVT start has so far been described. We aimed to analyze the clinical benefit of EVT and tPA from operation of the Melbourne MSU in the first year. Methods: First ambulance dispatch to reperfusion treatment commencement (DTT) times between MSU patients receiving reperfusion therapy from November 2017-18 were compared to consecutive control cases during MSU operating hours presenting across metropolitan Melbourne for tPA, and direct and metropolitan transfer patients presenting to the Royal Melbourne Hospital for EVT. Median time difference between MSU and controls was regarded as the 50th quantile using quantile regression analysis. Comparative disability avoidance was estimated for EVT and tPA using calculated time savings. Results: In the first calendar year, the MSU operated for 30.5 service (7-day) weeks. Prehospital tPA was administered to 52 patients, with median time differences for dispatch-to-hospital/scene-arrival of -30 minutes (p<0.0001) and arrival-to-tPA of -17 minutes (p=0.001), resulting in overall DTT time saving of 47 minutes compared to controls. In the same timeframe, 26 patients received EVT with median time difference of -51 minutes (p<0.0001) compared to controls. Prehospital notification resulted in median time difference of -17 minutes (p=0.001) for EVT center-arrival to groin puncture. Using published estimates of disability avoidance per minute of time saved for each reperfusion therapy, the clinical impact of the EVT time saving for the 26 MSU patients is equivalent to the clinical impact of 67 tPA patients treated on the MSU. Conclusion: The clinical impact of Melbourne MSU operation on earlier provision of EVT was greater than that of tPA in the first year of operation, reflecting facilitated triage to EVT centers and early prehospital notification. In locales where EVT capability is limited or unevenly distributed such as Melbourne, facilitation of EVT is likely to be a central driver of MSU operation.

Distribution of subclinical DWI lesions in patients with intracranial hemorrhage.

Sat, 13 Aug 2016 00:00:00 GMT

Title: Distribution of subclinical DWI lesions in patients with intracranial hemorrhage. Authors: Singhal S.; Chandra R.; Ma H.; Ly J.; Clissold B.; Srikanth V.; Phan T. Abstract: Background and Rationale: Subclinical ischemic lesions on diffusion weighted MR imaging (DWI) were recently described in patients with spontaneous intracerebral hemorrhage (ICH) and convexity subarachnoid hemorrhage (cSAH), possibly related to amyloid angiopathy. The topography of these lesions may provide clue regarding their pathogenesis with investigators suggesting preference of these lesions in watershed infarct location. The aim is to study the topography of these lesions. Method(s): Patients presenting to Monash Medical Centre between 2011-2014 with ICH and cSAH were included in the absence of aneurysm, arteriovenous malformation, hemorrhagic infarction, or contra-indication for Magnetic Resonance Imaging (MRI). Diffusion weighted imaging (DWI) lesions were segmented and registered to stereotactic coordinates. Their locations were compared to digital maps of arterial territory and watershed areas. Result(s): There were 114 eligible patients; mean age was 69.6 +/- 12.3 years (male 53.9%). The distribution of patients were cSAH 16 (14.0%), lobar ICH 48 (42.1%) and deep ICH 50 (43.9%). Among 30 patients (26%) who had DWI positive lesions, 16 (53.3%) occurred within 7 days and 29 (96.7%) by 6 months. The predominant locations were frontal 15/30 (50.0%), parietal 10/30 (33.3%) and subcortical 7/30 (23.3%). These locations and the haemorrhage types are displayed [convexity subarachnoid hemorrhage (red), lobar hemorrhage (blue) and deep hemorrhage (yellow)]. There were no statistical association between the DWI lesion locations and the type of intracranial haemorrhage. Conclusion(s): Subclinical ischemic lesions have random distribution and are not easily explained by current hypotheses.