Simple measurement of aneurysm residual after treatment: the SMART scale for evaluation of intracranial aneurysms treated with flow diverters.

BACKGROUND: Primary endovascular reconstruction with flow diversion represents a fundamental paradigm shift in the technique of endovascular aneurysm treatment. Unlike coil embolization, often there remains residual post-procedural filling within the aneurysm with flow diverters, the curative reconstruction presumably occurring over a period of weeks. Thus, conventional grading scales for post-procedural aneurysm occlusion and recanalization are inadequate. The aim of this paper is to propose a new angiographic grading scale that addresses this fundamentally new treatment option. METHOD: A five-point grading scale describes the location of residual flow within the aneurysm in the venous phase [grade 1: patent aneurysm with diffuse inflow; grade 2: residual filling of the aneurysm dome (saccular) or wall (fusiform); grade 3: only residual neck (saccular) or only intra-aneurysmal filling with former boundaries covered (fusiform); grade 4: complete occlusion]. FINDINGS: Grade 0 represents any aneurysm, regardless of occlusion rate with early phase, coherent inflow jet. Intra-aneurysmal flow stagnation is categorized into: (a) none, (b) capillary phase, and (c) venous phase. Prevailing parent vessel hemodynamics with in-stent stenosis (ISS) are divided into none (ISS0), mild (ISS1), moderate (ISS2), severe (ISS3), and total (ISS4) occlusion. The proposed grading scales allow assessment of the hemodynamic consequences of stent placement on endosaccular in-flow, stasis, and location of stasis as well as parent vessel hemodynamics. CONCLUSIONS: Further studies need to show the applicability and possible predictive value of this new grading scale on the efficacy of the stent in promoting intra-aneurysmal flow stagnation, thus creating the potential to harmonize the results of future papers. This may help to optimize treatment and future device design.

Anatomic Snuffbox (Distal Radial Artery) and Radial Artery Access for Treatment of Intracranial Aneurysms with FDA-Approved Flow Diverters.

BACKGROUND AND PURPOSE: Transradial access for neurointerventional procedures has been proved a safer and more comfortable alternative to femoral artery access. We present our experience with transradial (distal radial/anatomic snuffbox and radial artery) access for treatment of intracranial aneurysms using all 3 FDA-approved flow diverters. MATERIALS AND METHODS: This was a high-volume, dual-center, retrospective analysis of each institution's data base between June 2018 and June 2020 and a collection of all patients treated with flow diversion via transradial access. Patient demographic information and procedural and radiographic data were obtained. RESULTS: Seventy-four patients were identified (64 female patients) with a mean age of 57.5 years with a total of 86 aneurysms. Most aneurysms were located in the anterior circulation (93%) and within the intracranial ICA (67.4%). The mean aneurysm size was 5.5 mm. Flow diverters placed included the Pipeline Embolization Device (Flex) (PED, n = 65), the Surpass Streamline Flow Diverter (n = 8), and the Flow-Redirection Endoluminal Device (FRED, n = 1). Transradial access was successful in all cases, but femoral crossover was required in 3 cases (4.1%) due to tortuous anatomy and inadequate support of the catheters in 2 cases and an inability to navigate to the target vessel in a patient with an aberrant right subclavian artery. All 71 other interventions were successfully performed via the transradial approach (95.9%). No access site complications were encountered. Asymptomatic radial artery occlusion was encountered in 1 case (3.7%). CONCLUSIONS: Flow diverters can be successfully placed via the transradial approach with high technical success, low access site complications, and a low femoral crossover rate.

Local arterial nanoparticle delivery of siRNA for NOX2 knockdown to prevent restenosis in an atherosclerotic rat model.

Both atherosclerosis and arterial interventions induce oxidative stress mediated in part by nicotinamide adenine dinucleotide phosphate (NADPH) oxidases that have a pivotal role in the development of neointimal hyperplasia and restenosis. For small interfering RNA (siRNA) targeting of the NOX2 (Cybb) component of the NADPH oxidase to prevent restenosis, gene transfer with viral vectors is effective, but raises safety issues in humans. We developed a new approach using the amino-acid-based nanoparticle HB-OLD7 for local delivery of siRNA targeting NOX2 to the arterial wall. siRNA-nanoparticle complexes were transferred into the regional carotid artery walls after angioplasty in an atherosclerotic rat model. Compared with angioplasty controls, Cybb gene expression (measured by quantitative reverse transcriptase-PCR) in the experimental arterial wall 2 weeks after siRNA was reduced by >87%. The neointima-to-media-area ratio was decreased by >83%, and the lumen-to-whole-artery area ratio was increased by >89%. Vital organs showed no abnormalities and splenic Cybb gene expression showed no detectable change. Thus, local arterial wall gene transfer with HB-OLD7 nanoparticles provides an effective, nonviral system for efficient and safe local gene transfer in a clinically applicable approach to knock down an NADPH oxidase gene. Local arterial knockdown of the Cybb gene significantly inhibited neointimal hyperplasia and preserved the vessel lumen without systemic toxicity.

Robust initialization of 2D-3D image registration using the projection-slice theorem and phase correlation.

PURPOSE: The image registration literature comprises many methods for 2D-3D registration for which accuracy has been established in a variety of applications. However, clinical application is limited by a small capture range. Initial offsets outside the capture range of a registration method will not converge to a successful registration. Previously reported capture ranges, defined as the 95% success range, are in the order of 4-11 mm mean target registration error. In this article, a relatively computationally inexpensive and robust estimation method is proposed with the objective to enlarge the capture range. METHODS: The method uses the projection-slice theorem in combination with phase correlation in order to estimate the transform parameters, which provides an initialization of the subsequent registration procedure. RESULTS: The feasibility of the method was evaluated by experiments using digitally reconstructed radiographs generated from in vivo 3D-RX data. With these experiments it was shown that the projection-slice theorem provides successful estimates of the rotational transform parameters for perspective projections and in case of translational offsets. The method was further tested on ex vivo ovine x-ray data. In 95% of the cases, the method yielded successful estimates for initial mean target registration errors up to 19.5 mm. Finally, the method was evaluated as an initialization method for an intensity-based 2D-3D registration method. The uninitialized and initialized registration experiments had success rates of 28.8% and 68.6%, respectively. CONCLUSIONS: The authors have shown that the initialization method based on the projection-slice theorem and phase correlation yields adequate initializations for existing registration methods, thereby substantially enlarging the capture range of these methods.

Histological stroke clot analysis after thrombectomy: Technical aspects and recommendations.

The recent advent of endovascular procedures has created the unique opportunity to collect and analyze thrombi removed from cerebral arteries, instigating a novel subfield in stroke research. Insights into thrombus characteristics and composition could play an important role in ongoing efforts to improve acute ischemic stroke therapy. An increasing number of centers are collecting stroke thrombi. This paper aims at providing guiding information on thrombus handling, procedures, and analysis in order to facilitate and standardize this emerging research field.

Complex-shaped platinum coils for brain aneurysms: higher packing density, improved biomechanical stability, and midterm angiographic outcome.

BACKGROUND AND PURPOSE: Five to 60% of coiled brain aneurysms recanalize, generally because of coil compaction. In vitro exclusive use of complex-shaped coils allows better packing of the aneurysmal sac and the neck as compared with helical coils. We report a single-center, prospective study using complex coils. Safety, packing density, and recanalization rate were evaluated. MATERIALS AND METHODS: Seventy-seven aneurysms were embolized using complex coils alone. Aneurysms had a volume of 265 mm3 (diameter: 7.1+/-3.3 mm) and a neck size of 4.1+/-1.8 mm (range: 1.5-12 mm). Average follow-up available in 31 patients was 10.5+/-7.6 months (range: 3-36 months). Primary angiographic endpoints included aneurysmal recanalization and (re)rupture. Primary adverse events included stroke or death. RESULTS: Complete or near-complete occlusion was achieved in all of the aneurysms but required balloon assistance in 24.6%. The packing density was computed as 37%+/-13%. No rerupture was observed during the follow-up interval. Recanalization was seen in 4 (12.9%) of 31. Two basilar tip aneurysms underwent a safe and complete recoiling. Periprocedural nondevice-related neurologic deficits were seen in 2 (2.9%) of 69 patients. CONCLUSIONS: The use of complex-shaped coils allows higher packing density, which may improve the recanalization rate. Basilar tip aneurysms remain a challenge.

Reduced Patient Radiation Exposure during Neurodiagnostic and Interventional X-Ray Angiography with a New Imaging Platform.

BACKGROUND AND PURPOSE: Advancements in medical device and imaging technology as well as accruing clinical evidence have accelerated the growth of the endovascular treatment of cerebrovascular diseases. However, the augmented role of these procedures raises concerns about the radiation dose to patients and operators. We evaluated patient doses from an x-ray imaging platform with radiation dose-reduction technology, which combined image noise reduction, motion correction, and contrast-dependent temporal averaging with optimized x-ray exposure settings. MATERIALS AND METHODS: In this single-center, retrospective study, cumulative dose-area product inclusive of fluoroscopy, angiography, and 3D acquisitions for all neurovascular procedures performed during a 2-year period on the dose-reduction platform were compared with a reference platform. Key study features were the following: The neurointerventional radiologist could select the targeted dose reduction for each patient with the dose-reduction platform, and the statistical analyses included patient characteristics and the neurointerventional radiologist as covariates. The analyzed outcome measures were cumulative dose (kerma)-area product, fluoroscopy duration, and administered contrast volume. RESULTS: A total of 1238 neurointerventional cases were included, of which 914 and 324 were performed on the reference and dose-reduction platforms, respectively. Over all diagnostic and neurointerventional procedures, the cumulative dose-area product was significantly reduced by 53.2% (mean reduction, 160.3 Gy × cm2; P < .0001), fluoroscopy duration was marginally significantly increased (mean increase, 5.2 minutes; P = .0491), and contrast volume was nonsignificantly increased (mean increase, 15.3 mL; P = .1616) with the dose-reduction platform. CONCLUSIONS: A significant reduction in patient radiation dose is achievable during neurovascular procedures by using dose-reduction technology with a minimal impact on workflow.

Emergent Endovascular Management of Long-Segment and Flow-Limiting Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents.

BACKGROUND AND PURPOSE: Although most cervical dissections are managed medically, emergent endovascular treatment may become necessary in the presence of intracranial large-vessel occlusions, flow-limiting and long-segment dissections with impending occlusion, and/or hypoperfusion-related ischemia at risk of infarction. We investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting. MATERIALS AND METHODS: We retrospectively studied long-segment carotid dissections requiring stent reconstruction with multiple tandem stents (≥3 stents) and presenting with acute (<12 hours) ischemic stroke symptoms (NIHSS score, ≥4). We analyzed patient demographics, vascular risk factors, clinical presentations, imaging/angiographic findings, technical procedures/complications, and clinical outcomes. RESULTS: Fifteen patients (mean age, 51.5 years) with acute ischemic stroke (mean NIHSS score, 15) underwent endovascular stent reconstruction for vessel and/or ischemic tissue salvage. All carotid dissections presented with >70% flow limiting stenosis and involved the distal cervical ICA with a minimum length of 3.5 cm. Carotid stent reconstruction was successful in all patients with no residual stenosis or flow limitation. Nine patients (60%) harbored intracranial occlusions, and 6 patients (40%) required intra-arterial thrombolysis/thrombectomy, achieving 100% TICI 2b-3 reperfusion. Two procedural complications were limited to thromboembolic infarcts from in-stent thrombus and asymptomatic hemorrhagic infarct transformation (7% morbidity, 0% mortality). Angiographic and ultrasound follow-up confirmed normal carotid caliber and stent patency, with 2 cases of <20% in-stent stenosis. Early clinical improvement resulted in a mean discharge NIHSS score of 6, and 9/15 (60%) patients achieved a 90-day mRS of ≤2. CONCLUSIONS: Emergent stent reconstruction of long-segment and flow-limiting carotid dissections in acute ischemic stroke intervention is safe and effective, with favorable clinical outcomes, allowing successful thrombectomy, vessel salvage, restoration of cerebral perfusion, and/or prevention of recurrent thromboembolic stroke.

Surpass Flow Diverter for Treatment of Posterior Circulation Aneurysms.

BACKGROUND AND PURPOSE: Flow diverters for the treatment of posterior circulation aneurysms remain controversial. We aimed to identify factors contributing to outcome measures in patients treated with the Surpass flow diverter for aneurysms in this location. MATERIALS AND METHODS: We conducted an observational study of 53 patients who underwent flow-diverter treatment for posterior circulation aneurysms at 15 centers. Key outcome measures were mortality, complete aneurysm occlusion, and modified Rankin Scale score at follow-up. RESULTS: At follow-up (median, 11.3 months; interquartile range, 5.9-12.7 months), 9 patients had died, resulting in an all-cause mortality rate of 17.3% (95% CI, 7%-27.6%); 7 deaths (14%) were directly related to the procedure and none occurred in patients with a baseline mRS score of zero. After adjusting for covariates, a baseline mRS of 3-5 was more significantly (P = .003) associated with a higher hazard ratio for death than a baseline mRS of 0-2 (hazard ratio, 17.11; 95% CI, 2.69-109.02). After adjusting for follow-up duration, a 1-point increase in the baseline mRS was significantly (P < .001) associated with higher values of mRS at follow-up (odds ratio, 2.93; 95% CI, 1.79-4.79). Follow-up angiography in 44 patients (median, 11.3 months; interquartile range, 5.9-12.7 months) showed complete aneurysm occlusion in 29 (66%; 95% CI, 50.1%-79.5%). CONCLUSIONS: Clinical results of flow-diverter treatment of posterior circulation aneurysms depend very much on patient selection. In this study, poorer outcomes were related to the treatment of aneurysms in patients with higher baseline mRS scores. Angiographic results showed a high occlusion rate for this subset of complex aneurysms.

Elastase-induced aneurysms in rabbits: effect of postconstruction geometry on final size.

BACKGROUND AND PURPOSE: Elastase-induced aneurysms in rabbits have become an accepted model to study endovascular treatment. The size and shape of the resulting aneurysms may vary widely. Our goal was to predict the final aneurysm morphology on the basis of immediate postinduction geometry. METHODS: Thirty New Zealand white rabbits were used. Aneurysms were created at the origin of the right common carotid artery (CCA). Intraluminal incubation of elastase was applied to the origin of CCA with proximal balloon occlusion of the artery. The aneurysms were allowed to mature for 3 weeks and evaluated by digital subtraction angiography. We retrospectively measured neck diameter, dome height, and aneurysm diameter, as well as the angle between the parent artery and the main axis of the aneurysm neck. We performed correlation analysis with immediate postinduction geometry. RESULTS: The diameter of the origin of the CCA measured immediately after elastase incubation correlated positively to the mature aneurysm neck (P < .01). Moreover, the aneurysm neck both after the aneurysm creation and at 3-week follow-up had a positive correlation with the final dome height (P < .05). Finally, the dome height was related to the angle between the centerline of the innominate artery and axis of the aneurysm neck for dome diameter-to-neck ratio of <1.5 (P < .05). CONCLUSION: These results indicate that neck width immediately after creation and the curvature of the parent artery are linked to the final aneurysm dimensions, and we may be able to predict the size of aneurysm on the day of creation.

Acute and chronic swine rete arteriovenous malformation models: effect of ethiodol and glacial acetic acid on penetration, dispersion, and injection force of N-butyl 2-cyanoacrylate.

BACKGROUND AND PURPOSE: Liquid embolic agents are increasingly gaining importance in the embolization of cerebral arteriovenous malformations (AVMs). Currently, the most commonly used agent is N-butyl 2-cyanoacrylate (NBCA). Various NBCA mixtures, arterial hypotension, and Valsalva maneuver (increased positive end-expiratory pressure) during the injection of the acrylate have been used to address hemodynamic and architectural variations of an AVM; however, the precise in vivo polymerization, distribution, and kinetics of NBCA mixtures are unknown. We investigated the effect of different acrylate/Lipiodol mixtures and the addition of glacial acetic acid (GAA) on the penetration, dispersion, and injection force of NBCA. METHODS: A swine rete AVM model that has been described elsewhere was used for the embolization. In one subgroup of animals, embolization was performed immediately after construction of the AVM model. In a second subgroup, a chronic AVM model was used. GAA was added to the NBCA mixture to decrease the pH value of the solution and prolong the polymerization time. The addition of GAA allowed us to reduce the amount of Lipiodol, thereby reducing the viscosity of the mixture. A total of 30 swine were used for both the acute (n = 23) and chronic (n = 7) subgroups. The following mixtures of Lipiodol/NBCA and GAA (% vol/%vol + microL) were used for embolization: 80/20 + 0; 50/50 + 0; 50/50 + 5; 50/50 + 10; and 50/50 + 20. A total of six retia per mixture were used for the analysis. Glue injection pressure profiles were recorded in each experiment. High-resolution radiographic images obtained from the harvested retia were used to correlate the dispersion and depth of glue penetration with the AVM hemodynamics. The effect of different amounts of GAA on the glue dispersion and depth of penetration of the mixtures was also studied. RESULTS: Using the same pressure gradients, less viscous NBCA + GAA mixtures led to a deeper nidal penetration. The addition of 20 microL of GAA resulted in a three times higher penetration and dispersion of the NBCA mixture that was more homogenous. CONCLUSION: The viscosity of the liquid embolic agent used is an important limiting factor for an AVM embolization. Reducing the amount of Lipiodol improves nidus penetration. Quicker polymerization can be overcome by adding GAA, which reduces the pH of the mixture.

Acute and chronic swine rete arteriovenous malformation models: hemodynamics and vascular remodeling.

BACKGROUND AND PURPOSE: An acute and a chronic arteriovenous malformation (AVM) model were developed by using the swine rete to study hemodynamics and vascular remodeling. The models were also used to study in vivo polymerization kinetics and the distribution of various N-butyl 2-cyanoacrylate (NBCA) and Lipiodol mixtures. METHODS: In the acute swine AVM model, retrograde flow through the left side of the rete was created by the placement of an endovascular shunt through the ipsilateral ascending pharyngeal artery. In the chronic model, flow was redirected retrograde through the left side of rete and ascending pharyngeal artery by creating an arteriovenous fistula between the ipsilateral jugular vein and the common carotid artery. After a period of at least 6 months, the entire head with the rete was connected to a perfusion loop driven by a peristaltic pump. A total of 30 swine were used for both the acute (n = 23) and chronic groups (n = 7). Hemodynamic parameters, including the flow and pressure drop across the rete, were recorded before NBCA embolization. Image processing was used on high-resolution radiographs of the explanted retia to measure the total rete length. Measurements of rete vessel calibers were based on histology. RESULTS: The pressure gradients across retia were higher in the chronic model than in the acute model, but they did not reach the level of statistical significance (23.7 +/- 12.0 mm Hg vs 15.4 +/- 1.4 mm Hg). The rete blood outflow was significantly higher in the chronic model compared with the acute one (139.9 +/- 100.3 mL/min vs 32.5 +/- 17.6; P = .03). The rete length in the chronic model was significantly higher than in the acute model (593.1 +/- 39.9 vs 401.3 +/- 65.2 pixel; P < .001). The average vessel diameter of the rete in the chronic group was 520 microm and 320 microm in the control animals. CONCLUSION: Increased pressure gradients and flow in the chronic swine rete AVM model may be related to increased size and decreased impedance. The resulting hemodynamic changes reflect a true flow-induced vascular remodeling rather than a simple change related to aging and size of the animal.

MR imaging of myeloperoxidase activity in a model of the inflamed aneurysm wall.

BACKGROUND AND PURPOSE: Although myeloperoxidase activity in vivo can be visualized by using noninvasive imaging, successful clinical translation requires further optimization of the imaging approach. We report a motion-sensitized driven-equilibrium MR imaging approach for the detection of a myeloperoxidase activity-specific gadolinium-containing imaging agent in experimental aneurysm models, which compensates for irregular blood flow, enabling vascular wall imaging in the aneurysm. MATERIALS AND METHODS: A phantom was built from rotational angiography of a rabbit elastase aneurysm model and was connected to a cardiac pulse duplicator mimicking rabbit-specific flow conditions. A T1-weighted turbo spin-echo-based motion-sensitized driven-equilibrium pulse sequence was optimized in vitro, including the addition of fat suppression and the selection of the velocity-encoding gradient parameter. The optimized sequence was applied in vivo to rabbit aneurysm models with and without inflammation in the aneurysmal wall. Under each condition, the aneurysms were imaged before and after intravenous administration of the imaging agent. The signal-to-noise ratio of each MR imaging section through the aneurysm was calculated. RESULTS: The motion-sensitized driven-equilibrium sequence was optimized to reduce flow signal, enabling detection of the myeloperoxidase imaging agent in the phantom. The optimized imaging protocol in the rabbit model of saccular aneurysms revealed a significant increase in the change of SNR from pre- to post-contrast MR imaging in the inflamed aneurysms compared with naïve aneurysms and the adjacent carotid artery (P < .0001). CONCLUSIONS: A diagnostic MR imaging protocol was optimized for molecular imaging of a myeloperoxidase-specific molecular imaging agent in an animal model of inflamed brain aneurysms.

Surpass flow diverter in the treatment of intracranial aneurysms: a prospective multicenter study.

BACKGROUND AND PURPOSE: Incomplete occlusion and recanalization of large and wide-neck brain aneurysms treated by endovascular therapy remains a challenge. We present preliminary clinical and angiographic results of an experimentally optimized Surpass flow diverter for treatment of intracranial aneurysms in a prospective, multicenter, nonrandomized, single-arm study. MATERIALS AND METHODS: At 24 centers, 165 patients with 190 intracranial aneurysms of the anterior and posterior circulations were enrolled. The primary efficacy end point was the percentage of intracranial aneurysms with 100% occlusion on 6-month DSA. The primary safety end point was neurologic death and any stroke through a minimum follow-up of 6 months. RESULTS: Successful flow-diverter delivery was achieved in 161 patients with 186 aneurysms (98%); the mean number of devices used per aneurysm was 1.05. Clinical follow-up (median, 6 months) of 150 patients (93.2%), showed that the primary safety end point occurred in 18 subjects. Permanent neurologic morbidity and mortality were 6% and 2.7%, respectively. Morbidity occurred in 4% and 7.4% of patients treated for aneurysms of the anterior and posterior circulation, respectively. Neurologic death during follow-up was observed in 1.6% and 7.4% of patients with treated intracranial aneurysms of the anterior and posterior circulation, respectively. Ischemic stroke at ≤30 days, SAH at ≤7 days, and intraparenchymal hemorrhage at ≤7 days were encountered in 3.7%, 2.5%, and 2.5% of subjects, respectively. No disabling ischemic strokes at >30 days or SAH at >7 days occurred. New or worsening cranial nerve deficit was observed in 2.7%. Follow-up angiography available in 158 (86.8%) intracranial aneurysms showed 100% occlusion in 75%. CONCLUSIONS: Clinical outcomes of the Surpass flow diverter in the treatment of intracranial aneurysms show a safety profile that is comparable with that of stent-assisted coil embolization. Angiographic results showed a high rate of intracranial aneurysm occlusion.

Modification of a previously described arteriovenous malformation model in the swine: endovascular and combined surgical/endovascular construction and hemodynamics.

BACKGROUND AND PURPOSE: The rete mirabile in swine has been proposed as an arteriovenous malformation (AVM) model for acute experimental studies through surgical creation of a large carotid-jugular fistula. This report describes two endovascular modifications to simplify the surgical creation and provides hemodynamic parameters for the AVM model. METHODS: An AVM model was created in 29 animals to study n-butyl 2-cyanoacrylate polymerization kinetics. The common carotid artery (CCA) was punctured and a guiding catheter was inserted tightly into the origin of the ascending pharyngeal artery (APA). The CCA was ligated proximal to the catheter to create a pressure drop across the rete, which represented the AVM nidus. The catheter hub was opened whenever needed and served as the venous drainage of the AVM nidus. The contralateral APA served as the arterial feeder. Instead of the surgical ligation of the CCA, a temporary balloon occlusion was performed in three animals. RESULTS: A mean pressure gradient of 14.9 +/- 10.5 mm Hg (range, 4-42 mm Hg) was measured across the rete. The mean flow rate was 30.4 +/- 14.2 mL/min (range, 3.5-46 mL/min), as measured at the venous drainage. CONCLUSION: The endovascular and combined surgical-endovascular rete AVM model in swine is easy to construct and is less time-consuming than are the currently used models for acute experimental studies. Hemodynamic parameters can be monitored during the entire experiment and correspond to values found in human cerebral AVMs.

Porcine brachial artery tortuosity for in vivo evaluation of neuroendovascular devices.

We report a novel model of arterial tortuosity in the porcine brachial artery for testing of endovascular devices in the flexed forelimb position. This provides an ideal vascular territory for an in vivo assessment of guidewires, microcatheters, and endovascular implants because it closely mimics the challenging curvature at the carotid siphon.

Reduction of coil mass artifacts in high-resolution flat detector conebeam CT of cerebral stent-assisted coiling.

BACKGROUND AND PURPOSE: Developments in flat panel angiographic C-arm systems have enabled visualization of both the neurovascular stents and host arteries in great detail, providing complementary spatial information in addition to conventional DSA. However, the visibility of these structures may be impeded by artifacts generated by adjacent radio-attenuating objects. We report on the use of a metal artifact reduction algorithm for high-resolution contrast-enhanced conebeam CT for follow-up imaging of stent-assisted coil embolization. MATERIALS AND METHODS: Contrast-enhanced conebeam CT data were acquired in 25 patients who underwent stent-assisted coiling. Reconstructions were generated with and without metal artifact reduction and were reviewed by 3 experienced neuroradiologists by use of a 3-point scale. RESULTS: With metal artifact reduction, the observers agreed that the visibility had improved by at least 1 point on the scoring scale in >40% of the cases (κ = 0.6) and that the streak artifact was not obscuring surrounding structures in 64% of all cases (κ = 0.6). Metal artifact reduction improved the image quality, which allowed for visibility sufficient for evaluation in 65% of the cases, and was preferred over no metal artifact reduction in 92% (κ = 0.9). Significantly higher scores were given with metal artifact reduction (P < .0001). CONCLUSIONS: Although metal artifact reduction is not capable of fully removing artifacts caused by implants with high x-ray absorption, we have shown that the image quality of contrast-enhanced conebeam CT data are improved drastically. The impact of the artifacts on the visibility varied between cases, and yet the overall visibility of the contrast-enhanced conebeam CT with metal artifact reduction improved in most the cases.

Finding the striatum in sheep: use of a multi-modal guided approach for convection enhanced delivery.

Our goal is delivery of a long-term treatment for Huntington's disease. We administer intracerebrally in sheep adeno-associated virus (AAV) to establish optimal safety, spread and neuronal uptake of AAV based therapeutics. Sheep have large gyrencephalic brains and offer the opportunity to study a transgenic Huntington's disease model. However, lack of a relevant brain stereotactic atlas and the difficulty of skull fixation make conventional stereotaxy unreliable. We describe a multi-modal image-guidance technique to achieve accurate placement of therapeutics into the sheep striatum.

Effectiveness of mechanical endovascular thrombectomy in a model system of cerebrovascular occlusion.

BACKGROUND AND PURPOSE: A number of thrombectomy devices are currently undergoing clinical evaluation; meanwhile, various novel devices are under investigation. The aims of this study were to quantify flow restoration and the particle size distribution of the effluent pursuant to MET in an in vitro occlusion model. MATERIALS AND METHODS: The model system was composed of 3 elements: an ICA/MCA replica, a clot model with mechanical properties similar to those of thrombi found in patients at risk of stroke, and a pulsatile flow loop. Different thrombectomy mechanisms including mechanical retrieval, aspiration, and waveguide induced cavitation were used. The efficacy end points were recanalization rate and amount of flow restoration. The risk of the embolic shower was assessed to evaluate device safety. RESULTS: The recanalization rates were the following: Merci, 67%; Solitaire, 100%; Penumbra, 83%; Enterprise, 17%; and the waveguide, 0%. In experiments in which recanalization was achieved, the amount of flow restoration for the Merci, Solitaire, and Enterprise devices was 100%, 92%, and 86%, respectively. The mean sizes of generated small and large clot fragments were between 23 and 37 and 215 and 285 µm, respectively, depending on the device used. The Merci device generated the fewest number of large fragments compared with the Penumbra system (P < .05) and Solitaire (not significant). CONCLUSIONS: The risk of embolic shower was influenced by the mechanism of action for the thrombectomy device. Clinically reported recanalization rates for the Solitaire, Penumbra, and Merci devices were nearly identical in this model system, suggesting that this model may provide a predictive tool for preclinical evaluation of MET.

Closed-cell stent for coil embolization of intracranial aneurysms: clinical and angiographic results.

BACKGROUND AND PURPOSE: Recanalization is observed in 20-40% of endovascularly treated intracranial aneurysms. To further reduce the recanalization and expand endovascular treatment, we evaluated the safety and efficacy of closed-cell SACE. MATERIALS AND METHODS: Between 2007 and 2010, 147 consecutive patients (110 women; mean age, 54 years) presenting at 2 centers with 161 wide-neck ruptured and unruptured aneurysms were treated by using SACE. Inclusion criteria were wide-neck aneurysms (>4 mm or a dome/neck ratio ≤ 2). Clinical outcomes were assessed by the mRS score at baseline, discharge, and follow-up. Aneurysm occlusion was assessed on angiograms by using the RS immediately after SACE and at follow-up. RESULTS: Eighteen aneurysms (11%) were treated following rupture. Procedure-related mortality and permanent neurologic deficits occurred in 2 (1.4%) and 5 patients (3.4%), respectively. In total, 7 patients (4.8%) died, including 2 with reruptures. Of the 140 surviving patients, 113 (80.7%) patients with 120 aneurysms were available for follow-up neurologic examination at a mean of 11.8 months. An increase in mRS score from admission to follow-up by 1, 2, or 3 points was seen in 7 (6.9%), 1 (1%), and 2 (2%) patients, respectively. Follow-up angiography was performed in 120 aneurysms at a mean of 11.9 months. Recanalization occurred in 12 aneurysms (10%), requiring retreatment in 7 (5.8%). Moderate in-stent stenosis was seen in 1 (0.8%), which remained asymptomatic. CONCLUSIONS: This series adds to the evidence demonstrating the safety and effectiveness of SACE in the treatment of intracranial aneurysms. However, SACE of ruptured aneurysms and premature termination of antiplatelet treatment are associated with increased morbidity and mortality.