Cerebral arteriovenous fistulae.

Dural arteriovenous fistulae (dAVFs) are diverse, complex lesions that share the common feature of arteriovenous shunting without an intervening nidus. In this chapter, the ensuing discussion is organized by dAVF location, followed by further consideration of less common, distinct types of dAVFs-carotid cavernous fistulae, pial arteriovenous fistulae, and vein of Galen malformations. For each lesion type, epidemiology, clinical presentation, imaging findings, classification considerations, and treatment options are discussed.

Virtual 2D angiography from four-dimensional digital subtraction angiography (4D-DSA): A feasibility study.

BACKGROUND: Digital subtraction angiography (DSA) remains the gold standard for angiographic evaluation of cerebrovascular pathology, however, multiple acquisitions requiring additional time and radiation are often needed. In contrast, 3D-DSA provides volumetric information from a single injection but neglects temporal information. Four-dimensional-DSA (4D-DSA) combines temporal information of 2D-DSA with volumetric information of 3D-DSA to provide time-resolved tomographic 3D reconstructions, potentially reducing procedure time and radiation. This work evaluates the diagnostic quality of virtual single-frame 4D-DSA relative to 2D-DSA images by assessing clinicians' ability to evaluate cerebrovascular pathology. METHODS: Single-frame images of four projections from 4D-DSA and their corresponding 2D-DSA images (n = 15) were rated by two neurointerventional radiologists. Images were graded based on diagnostic quality (0 = non-diagnostic, 1 = poor, 2 = acceptable, 3 = good). Dose area product (DAP) for each case was recorded for all 2D-DSA, 4D-DSA acquisitions, and the overall procedure. RESULTS: The mean diagnostic quality of all four 4D-DSA projections from both raters was 1.75 while the mean of 2D-DSA projections was 2.8. Student's t-test revealed significant difference in diagnostic quality between 4D-DSA and 2D-DSA at all four projections (p < 0.001). On average 4D-DSA acquisitions accounted for 30% dose compared to the overall average aggregated dose per procedure. CONCLUSIONS: The difference in image quality between virtual single-frame 4D-DSA and their respective 2D-DSA images is statistically significant. Furthermore, 4D-DSA acquisitions require less radiation dose than conventional procedures with 2D-DSA acquisitions.

Improving mechanical thrombectomy time metrics in the angiography suite: Stroke cart, parallel workflows, and conscious sedation.

Purpose Earlier reperfusion of large-vessel occlusion (LVO) stroke improves functional outcomes. We hypothesize that use of a stroke cart in the angiography suite, containing all commonly used procedural equipment in a mechanical thrombectomy, combined with parallel staff workflows, and use of conscious sedation when possible, improve mechanical thrombectomy time metrics. Methods We identified 47 consecutive LVO patients who underwent mechanical thrombectomy at our center, retrospectively and prospectively from implementation of these three workflow changes (19 pre- and 28 post-). For each patient, last known normal, NIHSS, angiography suite in-room time, type of anesthesia, groin puncture time, on-clot time, recanalization time, LVO location, number of passes, device(s) used, mTICI score, and outcome (mRS) were recorded. Between-group comparisons of time metrics and multivariate regression were performed. Results Stroke cart, parallel workflows, and primary use of conscious sedation decreased in-room time to groin puncture (-21.3 min, p < 0.0001), in-room to on-clot time (-24.1 min, p = 0.001), and in-room to reperfusion time (-29.5 min, p = 0.01). In a multivariate analysis, endotracheal intubation and general anesthesia were found to significantly increase in-room to on-clot time ( p = 0.01), in-room to reperfusion time ( p = 0.01), and groin puncture to on-clot time ( p = 0.05). The number of patients achieving a good outcome (mRS 0-2), however, did not significantly differ between the two groups (9/18 (47%) vs 14/28 (50%), p = 0.60). Conclusions Use of a stroke cart, parallel workflows by neurointerventionalists, technologists, and nursing staff, and use of conscious sedation may be useful to other institutions in efforts to improve procedural times.

Estimation of intra-arterial chemotherapy distribution to the retina in pediatric retinoblastoma patients using quantitative digital subtraction angiography.

Background and purpose The purpose of this article is to estimate the distribution of superselective intra-arterial chemotherapy (IAC) delivery to ocular target tissue using quantitative digital subtraction angiography (qDSA). Materials and methods From March 2010 to January 2016, 50 ophthalmic artery contrast DSAs obtained immediately prior to IAC infusions in 22 patients were analyzed. This study was conducted under a retrospective review IRB (no. 10-01862). Parametric color-coded DSAs (iFlow, Siemens Medical) were post-processed (MATLAB, The Mathworks Inc.) using two methods: two box regions of interest (pre-retina and globe) and four custom regions of interest (ROIs-ophthalmic artery, choroid, supraclinoid internal carotid artery (ICA), cavernous ICA). Mean interobserver reliability of custom ROI selection is presented as a 95% confidence interval of interclass correlation, and fractional chemotherapy delivery to selected ROIs as means ± standard deviation in this study. Results The estimated fraction of chemotherapy delivered to the globe with the first method was 79.5%. Percentage regional delivery using the second method was as follows: ophthalmic artery, 85.8%; choroid, 60.5%; supraclinoid ICA, 14.2%. The cavernous ICA ROI (encompassing distal catheter and potential reflux) gave a signal equivalent to 9.3% of total delivery. Conclusion Parametric color-coded qDSA can estimate the fraction of IAC delivered to the retina and other orbital structures in ocular retinoblastoma patients. This information can inform delivery location and dosing strategies on a patient-specific basis.

Transvenous ethanol sclerotherapy of feeding arteries for treatment of a dural arteriovenous fistula.

Dural arteriovenous fistulas (DAVFs) can be complex lesions that require a well trained eye for proper characterization and management decisions. With numerous possible arteries to supply and veins to drain them, DAVFs are often complex lesions. To best treat these complex lesions, the neurointerventionalist should be adept at treating them with multiple techniques. This report describes a unique case in which a DAVF was treated with arterial sclerotherapy using ethanol from a transvenous approach.

Technical factors affecting outcomes following endovascular treatment of posterior circulation atherosclerotic lesions.

BACKGROUND: Atherosclerotic disease of the vertebrobasilar system causes significant morbidity and mortality. All lesions require aggressive medical management, but the role of endovascular interventions remains unsettled. This study examines such endovascular interventions for vertebrobasilar atherosclerosis. METHODS: Retrospective review was performed of prospectively maintained procedure logs at three hospitals with comprehensive neurointerventional services. Patients with angiographically-proven stenosis undergoing elective stent placement were selected for analysis of demographic factors, lesion characteristics, and treatment details. Multivariate analysis was performed to evaluate for associations with ischemic stroke, death, and functional status as measured by modified Rankin scale at multiple intervals. RESULTS: One hundred and twenty-three lesions were treated in 110 patients. A total of 43 (58.1%) lesions caused stroke, while 66 (89.2%) caused transient ischemic attacks (TIAs). Forty lesions (32.5%) were at the vertebral origin; 97 (60.2%) were intracranial. A total of 112 (91.1%) were treated successfully. 4 (3.3%) of 10 (8.1%) procedural complications were symptomatic. Intracranial lesions were associated with death at 1 and 2 years (OR 24.91, P < 0.001) and mRS >2 at last contact (OR 12.83, P < 0.001). Stenting treatment with conjunctive angioplasty had lower rates of death (OR 0.303, P = 0.046) and mRS >2 at last contact (OR 0.234, P = 0.018) when angioplasty was performed with a device other than that packaged with the stent. CONCLUSION: Endovascular treatment of vertebrobasilar atherosclerosis can be performed safely, particularly for vertebral origin lesions. Higher rates of technical failure and complication may be acceptable for certain intracranial lesions due to their refractory nature and the morbidity caused by such lesions. Treatment should be tailored to features of each individual lesion.

Recurrence, retreatment, and rebleed rates of coiled aneurysms with respect to the Raymond-Roy scale: a meta-analysis.

BACKGROUND AND PURPOSE: The Raymond-Roy grading scale is used for aneurysm coiling with only limited data on its validity. The scale was developed based on the extent of initial aneurysm occlusion from 1 to 3. However, the model usefulness in evaluating recurrence, retreatment, and rebleeding is unknown. Our goal was to perform a meta-analysis to evaluate the predictiveness of the Raymond scale. METHODS: We performed a systematic review of the English literature for aneurysm coiling which reported the initial embolization results, based on the Raymond-Roy grading scale, and the respective recurrence rates, retreatment rates, and rebleed rates. This yielded data for 4587 aneurysms. We conducted a Bayesian random effects meta-analysis to evaluate the outcomes with respect to the reported initial embolization results. RESULTS: We found the Raymond scale to be predictive of retreatment, with statistically higher rates of retreatment with higher initial Raymond grade. Furthermore, we found a higher probability of rebleeding for initial grades 2 or 3 versus grade 1, which approached significance. The rebleed rates were probably affected by monitoring and treatment of recurrence. However, although there was a trend towards higher recurrence rates with initial grade, this was not statistically significant. CONCLUSIONS: The modified Raymond-Roy scale appears to provide reasonable predictive value for treated aneurysm, especially for the clinically more important aspects of retreatment and rebleed rates.

Transvenous ethanol sclerotherapy of feeding arteries for treatment of a dural arteriovenous fistula.

Dural arteriovenous fistulas (DAVFs) can be complex lesions that require a well trained eye for proper characterization and management decisions. With numerous possible arteries to supply and veins to drain them, DAVFs are often complex lesions. To best treat these complex lesions, the neurointerventionalist should be adept at treating them with multiple techniques. This report describes a unique case in which a DAVF was treated with arterial sclerotherapy using ethanol from a transvenous approach.

Using the Barrel Technique with the LVIS Jr (Low-profile Visualized Intraluminal Support) Stent to Treat a Wide Neck MCA Bifurcation Aneurysm.

The treatment of wide-neck bifurcation cerebral aneurysms is challenging especially if at least one of the arteries arise from an obtuse angle. These wide-neck bifurcation aneurysms are difficult to treat with the usual balloon and stent assisted coiling, including Y stenting or double-barrel stent techniques [1, 2]. Other available options include using current devices with the waffle cone or double waffle cone techniques [3, 4]. Novel devices that are in development include intrasaccular devices and the barrel bifurcation vascular reconstruction device (Covidien) [5, 6, 7]. We report the use of a novel barrel technique using the LVIS (low-profile visualized intraluminal support) Jr stent for the treatment of a wide-neck bifurcation aneurysm.

Human cord blood stem cell-modulated regulatory T lymphocytes reverse the autoimmune-caused type 1 diabetes in nonobese diabetic (NOD) mice.

BACKGROUND: The deficit of pancreatic islet beta cells caused by autoimmune destruction is a crucial issue in type 1 diabetes (T1D). It is essential to fundamentally control the autoimmunity for treatment of T1D. Regulatory T cells (Tregs) play a pivotal role in maintaining self-tolerance through their inhibitory impact on autoreactive effector T cells. An abnormality of Tregs is associated with initiation of progression of T1D. METHODOLOGY/PRINCIPAL FINDINGS: Here, we report that treatment of established autoimmune-caused diabetes in NOD mice with purified autologous CD4(+)CD62L(+) Tregs co-cultured with human cord blood stem cells (CB-SC) can eliminate hyperglycemia, promote islet beta-cell regeneration to increase beta-cell mass and insulin production, and reconstitute islet architecture. Correspondingly, treatment with CB-SC-modulated CD4(+)CD62L(+) Tregs (mCD4CD62L Tregs) resulted in a marked reduction of insulitis, restored Th1/Th2 cytokine balance in blood, and induced apoptosis of infiltrated leukocytes in pancreatic islets. CONCLUSIONS/SIGNIFICANCE: These data demonstrate that treatment with mCD4CD62L Tregs can reverse overt diabetes, providing a novel strategy for the treatment of type 1 diabetes as well as other autoimmune diseases.