A collaborative system for endovascular treatment of acute ischaemic stroke: the Madrid Stroke Network experience.

BACKGROUND AND PURPOSE: The complexity and expense of endovascular treatment (EVT) for acute ischaemic stroke (AIS) can present difficulties in bringing this approach closer to the patients. A collaborative node was implemented involving three stroke centres (SCs) within the Madrid Stroke Network to provide round-the-clock access to EVT for AIS. METHODS: A weekly schedule was established to ensure that at least one SC was 'on-call' to provide EVT for all those with moderate to severe AIS due to large vessel occlusion, >4.5 h from symptom onset, or within this time-window but with contraindication to, or failure of, systemic thrombolysis. The time-window for treatment was 8 h for anterior circulation stroke and <24 h in posterior stroke. Outcomes measured were re-canalization rates, modified Rankin Scale (mRS) score at 3 months, mortality and symptomatic intra-cranial haemorrhage (SICH). RESULTS: Over a 2-year period (2012-2013), 303 candidate patients with AIS were considered for EVT as per protocol, and 196 (65%) received treatment. Reasons for non-treatment were significant improvement (14%), spontaneous re-canalization (26%), clinical worsening (9%) or radiological criteria of established infarction (31%). Re-canalization rate amongst treated patients was 80%. Median delay from symptom onset to re-canalization was 323 min (p25; p75 percentiles 255; 430). Mortality was 11%; independence (mRS 0-2) was 58%; SICH was 3%. CONCLUSIONS: Implementation of a collaborative network to provide EVT for AIS is feasible and effective. Results are good in terms of re-canalization rates and clinical outcomes.

Guidelines for the treatment of acute ischaemic stroke.

INTRODUCTION: Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies. DEVELOPMENT: Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 °C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible. CONCLUSION: Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated.

Endovascular treatment of intracranial aneurysms using the Pipeline Flex embolization device: a case series of 30 consecutive patients.

BACKGROUND: The Pipeline Flex embolization device has some peculiarities in comparison with the previous generation device. Despite recent reports of the modified delivery system, its safety is still unknown. OBJECTIVE: To illustrate the intraprocedural and periprocedural complication rate with this new device in 30 consecutive patients. MATERIAL AND METHODS: Clinical, procedural, and angiographic data, including aneurysm size and location, device or devices used, angiographic and clinical data were analyzed. RESULTS: 30 patients harboring 30 aneurysms were analyzed. 39 devices were placed properly. Multiple Pipeline embolization devices (PEDs) were used in 7 cases. In 28 devices the distal end opened fully from the beginning with a complete wall apposition. In the remaining 11 devices, distal-end opening of the devices was instant but partial, but fully opened easily after recapture. Among the 30 procedures, recapture and reposition of the Pipeline Flex was performed four times owing to proximal migration/malposition of the device during delivery. Four intraprocedural/periprocedural complications occurred, of which 2 resulted in major complications, with neurologic deficits persisting for longer than 7 days. The 30-day morbidity rate was 6.6%, with no deaths. No aneurysm rupture or parenchymal hemorrhage was seen. CONCLUSIONS: The Pipeline Flex embolization device allows more precise and controlled deployment than the first-generation device. The number of devices and the complication rate during the learning curve are lower than reported with the first-generation PED. The new delivery system and the resheathing maneuvers do not seem to increase the intraprocedural complication rate in comparison with the first-generation PED.

Preliminary experience with the Pipeline Flex Embolization Device: technical note.

BACKGROUND: Clinical experience with the Pipeline Embolization Device (PED) has been widely described in the literature since it obtained its European CE and FDA approvals in 2008 and 2011, respectively. The new generation of PED, the Pipeline Flex Embolization Device, received the CE mark of approval in March 2014. While the implant composition has not changed, its new delivery system has some differences. One of the main changes from the previous generation is a new delivery system that makes the device resheathable until deployed over 90% of its length. We present our preliminary experience using this device. METHODS: Between May and June 2014, six patients with six aneurysms were treated with the Pipeline Flex device. RESULTS: All devices were placed properly, without technical difficulties. We successfully resheathed and repositioned the device in two cases. Minor and major intraprocedural or periprocedural events were noted. CONCLUSIONS: The Pipeline Flex device allows more precise and controlled deployment than the current PED device. Although this preliminary experience seems positive, multicenter larger series will be needed to confirm the safety and durability of this new device.

Pipeline endovascular device for the treatment of intracranial aneurysms at the level of the circle of Willis and beyond: multicenter experience.

BACKGROUND AND PURPOSE: The aim of our study was to evaluate the safety and efficacy of the pipeline endovascular device for the treatment of anterior circulation aneurysms at the level of the circle of Willis and beyond. METHODS: A consecutive series of 25 patients (24 unruptured and one ruptured) with anterior circulation aneurysms treated with a pipeline endovascular device were included in the analysis. RESULTS: We found two minor clinical events (resolved within 7 days of the procedure), one major event (symptoms present after 7 days), and no mortality. There were no aneurysm ruptures or parenchymal hemorrhages during follow-up. The modified Rankin Scale (mRS) scores at 3 and 6 months did not change from the prior mRS score for all cases except 1. There was one asymptomatic periprocedural event. There were three intraprocedural complications which resolved without clinical consequences. Six month follow-up angiograms were obtained for 22 aneurysms, showing complete occlusion in 14 (64%) and significantly decreased residual filling in 8 (36%). The status of branches originating from the aneurysm sacs was evaluated in 14 angiograms: 11 were patent (79%), 2 had moderate reduction (14%) and 1 (7%) was occluded. We found six cases of in-stent stenosis (27%) on 6 month DSA, with only one symptomatic case. CONCLUSIONS: The pipeline embolization device provides a feasible and technically safe solution for aneurysms at and beyond the circle of Willis. Preliminary results are promising but larger series with longer term follow-up examinations are required to show the long term safety and durability of this treatment alternative.

Arteriovenous fistula after temporomandibular joint arthroscopy successfully treated with embolization.

Temporomandibular joint arthoscopy is a minimal invasive surgical procedure commonly used to effectively treat some internal derangement of the TMJ. However, this method is not free of complications. Arteriovenous fistula (AVF) is a lesion that communicates the high flow arterial system and the low flow venous network. We describe a new case of preauricular traumatic AVF successfully treated with external carotid embolization, along with a review of the medical literature.

[The rupture of a cardiac hydatid cyst located in the right ventricle]. / Rotura de un quiste hidatídico cardíaco situado en ventrículo derecho.

Heart involvement in echinococcal disease is rare, but it is more infrequent the location of cysts in the right ventricle. We report a case of a male 35 years old with hydatid cysts located in the right ventricle. The condition was diagnosed by two-dimensional echocardiogram performed after the rupture of the cysts leading to massive pulmonary embolism and subsequently right heart failure. Early diagnosis appears mandatory in an attempt to modify, applying the appropriate therapy, the natural evolution of this potentially lethal condition.

[Fusiform aneurysm of the middle cerebral artery]. / Aneurisma fusiforme de la arteria cerebral media.

Introduction. The main objective of the treatment of intracranial aneurysms is to isolate them from the cerebral blood circulation. A fusiform aneurysm, because of its shape, cannot be treated using the usual techniques and usually requires techniques of arterial reconstruction and revascularization using by pass. Currently it is possible to find the vascular territories with the greatest risk of causing neurological defects and where revascularization is necessary. CASE REPORT. A 20 year old man with no previous history of illness who had several transient ischaemic episodes. Emergency laboratory tests, ECG and plain chest Xray were all normal. Imaging investigations showed the presence of a fusiform aneurysm of the anterosuperior division of the right middle cerebral artery. No associated systemic disease was detected. Wada s test showed the vascular territory with the greatest risk of neurological deficit. Extra intra cranial by pass was done from the right superficial temporal artery to the distal portion of the anteriorsuperior branch of this artery. The operation was done using a right pterion approach with dissection of the superficial temporal artery, and the aneurysm, trapping and termino lateral anastomosis. Cerebral protectors and mild hypothermia were used during the operation. The post operative course was uneventful. Anatomo pathological diagnosis was of an atherosclerotic fusiform aneurysm with osseous and chondroid metaplasia. After six months follow up the patient remains asymptomatic. Discussion and conclusions. Treatment of fusiform cerebral aneurysms is complex and usually requires procedures for cerebral revascularization. Correct pre operative evaluation is essential to identify the vascular territory with the greatest risk of causing neurological deficit. Wada s test is useful for this, since it permits selective evaluation of the different vascular territories safely and quickly. High or low flow by pass of these territories prevents cerebral ischaemia and permits the treatment of choice for these aneurysms.

[Neurovascular intervention in the acute phase of cerebral infarction]. / Intervencionismo neurovascular en la fase aguda del infarto cerebral.

BACKGROUND AND PURPOSE: Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid. METHODS: We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005-2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs). RESULTS: A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2-34]; 7 patients had previously received iv t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs ≤ 2) and overall mortality rate was 19.5%. CONCLUSIONS: Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with iv t-PA exclusion criteria or when this is not effective.