Best Practice Recommendations for Stroke Vascular Imaging During Iodinated Contrast Shortage.

GE Healthcare© announced on April 19, 2022, that their main factory and distributor of iodinated contrast had experienced a temporary shutdown because of COVID-19 outbreak in Shanghai, China. This, along with other supply chain issues, led to a worldwide shortage of iodinated contrast agents, Omnipaque and Visipaque. Our Comprehensive Stroke Center was confronted with the cascading effect of this iodinated contrast material shortage. We took immediate steps to revise our protocols and processes to continue to provide high-quality care to our stroke patients. A multidisciplinary working group comprised of representatives of our stroke center, including vascular neurology, diagnostic neuroradiology, and neurovascular surgery, urgently met to brainstorm how to mitigate the shortage. We established parameters and local guidelines for the use of CT angiography, CT perfusion, and digital subtraction angiography for stroke patients. In this article, we propose "best practice" recommendations from a single Joint Commission approved Comprehensive Stroke Center that can be used as blueprint by other hospital systems when navigating potential future supply chain issues, to provide consistent high-quality stroke care.

In vitro assessment of aortic stent-graft integrity following exposure to Onyx liquid embolic agent.

PURPOSE: Endovascular stent-grafts are increasingly being used for treatment of abdominal and thoracic aortic aneurysms. Postprocedural complications include development of endoleaks. Recently, an embolic agent known as Onyx has been employed to treat type II endoleaks. Onyx is a biocompatible copolymer dissolved in dimethyl sulfoxide (DMSO). Although DMSO is known to damage some angiographic catheters, little is known concerning whether this compound damages stent-graft material. The current study was undertaken to directly explore this issue. MATERIALS AND METHODS: Four stent-grafts were evaluated: the Excluder, Zenith, AneuRx, and Talent. Stent-grafts were incubated for 24 hours at 37 degrees C under each of the following conditions: DMSO alone, 50/50 mixture of DMSO/Onyx, mixture of 1 part 50/50 DMSO/Onyx and 9 parts whole blood, and untreated control. Stent-grafts were microdissected into 15-mm sections, after which they were evaluated with scanning electron microscopy. RESULTS: No appreciable differences between stent-grafts exposed to DMSO and untreated controls were seen. Although liquid embolic agent was seen coating stent-grafts exposed to a 50/50 mixture of DMSO and Onyx, no evidence of fiber breakdown was noted. Stent-grafts exposed to DMSO/Onyx/whole blood demonstrated a thin coating of clot and Onyx without visual evidence of fiber compromise. CONCLUSIONS: The current study provides compelling evidence that short-term exposure of endograft material to DMSO, DMSO/Onyx, or DMSO/Onyx/whole blood is not associated with acute structural compromise of four commonly used aortic endografts. Future in vivo studies will help to further establish the safety of this agent.

Introduction: Endovascular approaches to cerebral ischemia.

The treatment of stroke has rapidly evolved over the past decade, particularly as data concerning the natural history have emerged and endovascular treatment options have matured. Therapies for acute stroke have expanded as intraarterial thrombolysis and mechanical clot retrieval have been validated. Furthermore, angioplasty and stenting of intra- and extracranial vessels have evolved with the development of new devices coupled with increasing operator experience. Endovascular therapy is now a widely accepted treatment option for cerebral ischemia in many clinical situations.

Posterior circulation perforator aneurysms: a proposed management algorithm.

INTRODUCTION: Subarachnoid hemorrhage (SAH) from posterior circulation perforator aneurysms (PCPAs) is rare and its natural history is unknown. Diagnosis may be difficult, acute management is poorly defined, and long-term recurrent SAH rates and clinical outcome data are lacking. METHODS: We searched our institution's records for cases of PCPA rupture and analyzed patient demographics, Hunt and Hess (HH) grades, diagnostic imaging, management, and clinical outcomes. We conducted telephone interviews to calculate modified Rankin Scale (mRS) scores. RESULTS: We identified 9 patients (6 male, 3 female) with a ruptured PCPA who presented to the University of Virginia Health System (Charlottesville, VA, USA) between 2010 and 2016. Median and mean ages were 62 and 63 years, respectively. Median HH grade was 3. Seven of nine (78%) PCPAs were angiographically occult on initial imaging and median time to diagnosis was 5 days. Three conservatively managed patients had a mean mRS score of 0.67 (range 0-1) at mean follow-up of 35.3 months. Antifibrinolytic therapy was administered to all conservatively managed patients without thrombotic complication. Six patients receiving endovascular treatment had a mean mRS score of 2.67 (range 0-6) at mean follow-up of 49.2 months. No cases of recurrent SAH were seen in the study. CONCLUSIONS: The rarity of PCPA has precluded long-term clinical follow-up until now. Our experience suggests low recurrent SAH rates. Until further studies are performed, conservative management, possibly combined with antifibrinolytic therapy, may be a viable treatment with acceptable long-term outcome.

Development and psychometric properties of the Vertebral Compression Fracture Pain and Functional Disability Questionnaire.

OBJECT: Vertebral compression fractures (VCFs) result in severe and disabling pain, diminished quality of life, and substantial medical costs. There exists no standard instrument with which to measure pain and functional status before and after treatment of VCFs. METHODS: A questionnaire was specifically developed to assess pain and disability in patients with VCFs before and after undergoing percutaneous polymethylmethacrylate-augmented vertebroplasty. The first section of the baseline questionnaire (before treatment) contains 11 items that address the patient's previous and current levels of back pain and distress. The second section of the baseline questionnaire lists 24 activities of daily living (ADLs), each measured on a four-point scale ranging from "able to do without pain" to "cannot do because of pain." The follow-up questionnaire (after treatment) is similar in format. Among 72 vertebroplasty-treated patients, the internal consistency reliability of the 24 ADLs ranged from 0.87 to 0.98, with similar results observed before and after treatment. Correlations of 0.29 to 0.72 were observed among the 24 ADLs and the internal measures of pain and distress measured on both visual analog and adjectival scales. Similar correlations (range 0.35-0.63) were observed between the questionnaire and 10 dimensions of the Oswestry Disability Index's low-back pain questionnaire, an external instrument used to assess criterion-referenced validity. Evidence in support of the validity of the questionnaire was present before and after treatment. CONCLUSIONS: The Vertebral Compression Fracture Pain and Functional Disability Questionnaire appears to be a reliable and valid instrument for assessing back pain and functional ability in patients before and after treatment for VCFs.

Outcomes of vertebroplasty compared with kyphoplasty: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Many studies demonstrate that both kyphoplasty and vertebroplasty are superior to conservative therapy in the treatment of osteoporotic vertebral body compression fractures. We performed a systematic review and meta-analysis of studies comparing the outcomes of vertebroplasty and kyphoplasty, which included prospective non-randomized, retrospective comparative, and randomized studies. MATERIALS AND METHODS: We searched MEDLINE, EMBASE, and the Web of Science databases for studies of kyphoplasty versus vertebroplasty from 1 January 1990 to 30 November 2014 and compared the following outcomes: procedure characteristics, pain and disability improvement, complications and anatomic outcomes. A subgroup analysis was performed comparing pain outcomes based on the risk of bias. RESULTS: 29 studies enrolling 2838 patients (1384 kyphoplasty and 1454 vertebroplasty) were included. 16 prospective non-randomized studies, 10 retrospective comparative studies, and 3 randomized controlled studies were included. No significant differences were found in mean pain scores between the two groups postoperatively (2.9±1.5 kyphoplasty vs 2.9±1.7 vertebroplasty, p=0.39) and at 12 months (2.7±1.8 kyphoplasty vs 3.2±1.8 vertebroplasty, p=0.64). No significant differences were found in disability postoperatively (34.7±7.1 kyphoplasty group vs 36.3±7.8 vertebroplasty group, p=0.74) or at 12 months (28.3±16 kyphoplasty group vs 29.6±13.9 vertebroplasty group, p=0.70). Kyphoplasty was associated with lower odds of new fractures (p=0.06), less extraosseous cement leakage (p<0.01), and greater reduction in kyphotic angle (p<0.01). CONCLUSIONS: No significant difference was found between vertebroplasty and kyphoplasty in short- and long-term pain and disability outcomes. Further studies are needed to better determine if any particular subgroups of patients would benefit more from vertebroplasty or kyphoplasty in the treatment of vertebral body compression fractures.

Randomized controlled trial of vertebroplasty versus kyphoplasty in the treatment of vertebral compression fractures.

BACKGROUND: We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty versus kyphoplasty in treating vertebral body compression fractures. METHODS: Patients with vertebral body compression fractures were randomly assigned to treatment with kyphoplasty or vertebroplasty. Primary endpoints were pain (0-10 scale) and disability assessed using the Roland-Morris Disability Questionnaire (RMDQ). Outcomes were assessed at 3 days, 1 month, 6 months, and 1 year following the procedure. RESULTS: 115 subjects were enrolled in the trial with 59 (51.3%) randomly assigned to kyphoplasty and 56 (48.7%) assigned to vertebroplasty. Mean (SD) pain scores at baseline, 3 days, 30 days, and 1 year for kyphoplasty versus vertebroplasty were 7.4 (1.9) vs 7.9 (2.0), 4.1 (2.8) vs 3.7 (3.0), 3.4 (2.5) vs 3.6 (2.9), and 3.0 (2.8) vs 2.3 (2.6), respectively (p>0.05 at all time points). Mean (SD) RMDQ scores at baseline, 3 days, 30 days, 180 days, and 1 year were 17.3 (6.6) vs 16.3 (7.4), 11.8 (7.9) vs 10.9 (8.2), 8.6 (7.2) vs 8.8 (8.5), 7.9 (7.4) vs 7.3 (7.7), 7.5 (7.2) vs 6.7 (8.0), respectively (p>0.05 at all time points). For baseline to 12-month assessment in average pain and RMDQ scores, the standardized effect size between kyphoplasty and vertebroplasty was small at -0.36 (95% CI -1.02 to 0.31) and -0.04 (95% CI -1.68 to 1.60), respectively. CONCLUSIONS: Our study indicates that vertebroplasty and kyphoplasty appear to be equally effective in substantially reducing pain and disability in patients with vertebral body compression fractures. TRIAL REGISTRATION NUMBER: NCT00279877.

Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes.

OBJECTIVE: Embolization of cerebral arteriovenous malformations (AVMs) is commonly performed prior to surgical resection in order to reduce intraoperative bleeding and improve the safety of resection. Although most modern embolization procedures utilize permanent embolic agents, silk suture and polyvinyl alcohol (PVA) particles may offer unique advantages for preoperative devascularization. The aims of this retrospective cohort study are to describe the technical considerations and determine the outcomes for preoperative silk suture and PVA particle embolization (SPE) of AVMs. MATERIALS AND METHODS: We performed a retrospective review of our AVM embolization database. AVM patients who underwent preoperative SPE and subsequent surgical resection were included for analysis. Baseline patient demographics, AVM characteristics, embolization and operative records, and post-treatment outcomes were reviewed. RESULTS: A total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm3). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months). CONCLUSION: Preoperative AVM SPE affords a reasonable risk to benefit profile for appropriately selected patients.

Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. METHODS: A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. RESULTS: On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmologic complications were noted in either cohort. Complete occlusion at 12 months was more common following PED treatment than coil embolization (74% vs 47%; p=0.089), although lower than reported in previous trials. This may be due to inflow into the ophthalmic artery keeping the aneurysm patent. Retreatments were more common following coil embolization than PED (24% vs 11%), but this was not significant (p=0.304). Permanent morbidity rates were not significantly different between the PED (11%) and coil embolization (3%) cohorts (p=0.255). CONCLUSIONS: Our results suggest that ophthalmic artery aneurysms may be adequately and safely treated with either the PED or coil embolization. However, treatment with the PED carries a higher risk of impeding flow to the ophthalmic artery, although this did not result in clinical sequelae in the current study.

A method for complete angiographic obliteration of a brain arteriovenous malformation in a single session through a single pedicle.

Historically, the endovascular treatment of arteriovenous malformations (AVM) has largely been relegated to an adjunctive role to open surgical and radiosurgical methods. In this article, we describe a novel endovascular approach to the treatment of brain AVM using Onyx (ev3 Endovascular, Plymouth, MN, USA), which may allow for a complete angiographic obliteration in a single treatment session. Twelve patients underwent Onyx embolization of an AVM using a novel "reverse plug and push" technique in which a plug is formed around the treatment catheter prior to injecting Onyx into the AVM. The plug mitigates the risk of backflow and catheter entrapment, thereby allowing the user to inject higher volumes of Onyx at higher injection rates. Patient demographics, AVM characteristics, and treatment details were reviewed. Using the "reverse plug then push" technique, an average of 8.8 mL of Onyx was injected into the AVM in a single session. In every case, the microcatheter was removed easily with minimal traction pressure. Complete angiographic obliteration was achieved in 83% of patients after a single treatment. Morbidity and mortality were 8% each. The "reverse plug then push" technique allows for a more rapid injection of Onyx due to the formation of a well-controlled plug prior to treatment, mitigating the risk of catheter entrapment by Onyx reflux. With further refinement, this technique may present a viable curative option for treatment of select brain AVM.

Embolization of cerebral arteriovenous malformations with silk suture particles prior to stereotactic radiosurgery.

We aimed to determine the long term durability of silk suture and polyvinyl alcohol (PVA) particle embolization (SPE) of arteriovenous malformations (AVM), and to evaluate the outcomes following multimodality management of AVM with combined SPE and stereotactic radiosurgery (SRS). A general supposition among neurointerventionalists is that embolization of cerebral AVM with silk sutures and PVA particles does not yield a durable occlusion. We performed a retrospective review of all AVM patients treated at our institution with combined SPE and SRS. After extracting the baseline, embolization and SRS data for each patient, the durability of SPE was determined by evaluating the postembolization recanalization between the last procedural angiogram and the most recent neuroimaging. Four AVM patients who underwent a total of nine SPE procedures through 21 arterial pedicles were included for the analyses. The nidus volumes were 5.8-75 cm(3) and the Spetzler-Martin grades were II and V in one patient and III in two patients. The median degree of devascularization per procedure was <25%. There were no procedural complications, with all patients maintaining functional independence after embolization (modified Rankin scale score 0-2). After a median follow-up duration of 27 months (range: 23-36), there were no patients with recanalization. SRS (marginal dose 13-18 Gy) resulted in 40 to >95% volume reduction. Following SRS, one patient remained asymptomatic, two patients improved, and one patient deteriorated due to a latency period AVM hemorrhage. In conclusion, SPE can safely provide durable AVM devascularization, therefore, appropriately selected nidi can be effectively treated with combined SPE and SRS.

Stenting of symptomatic intracranial stenosis using balloon mounted coronary stents: a single center experience.

OBJECTIVE: Intracranial atherosclerotic disease is the cause of up to 10% of ischemic strokes and transient ischemic attacks. Intracranial stenting with off-label balloon mounted coronary stents (BMCS) may be a viable alternative for patients with symptomatic intracranial stenosis who fail best medical therapy. DESIGN: Between December 2005 and June 2012, 42 symptomatic intracranial stenoses were treated with a BMCS after failing medical management. Procedural records, clinical outcomes, and imaging follow-up were reviewed. Outcome measurements included technical success rate, morbidity and mortality, long term stent patency, and clinical outcomes, as measured by the modified Rankin Scale. RESULTS: The technical success rate was 98% (41 of 42 lesions). Morbidity within the first 30 days was 7.1% (three of 42 lesions). Overall morbidity, including both periprocedural and long term evaluation, was 9.5% (four of 42 lesions). There were no deaths. Follow-up imaging was available for 30 stents (71%) with an average follow-up time of 35.1 months. Restenosis (>50%) and retreatment were observed in 20% and 10% of cases, respectively. Clinical evaluation by a neurologist ≥ 30 days postprocedure was available in 40 of 42 cases (95%) with an average of 32.1 months. At presentation, 55% of patients had a modified Rankin Scale (mRS) score of ≤ 2. At follow-up, 74% of patients were found to have an mRS score of ≤ 2. CONCLUSIONS: This study suggests that BMCS may benefit patients with symptomatic intracranial stenosis who experience stroke or transient ischemic attack in spite of best medical therapy.

Intrathecal injection of contrast medium to prevent polymethylmethacrylate leakage during percutaneous vertebroplasty.

The major technical drawback of percutaneous vertebroplasty is the potential for neural compromise from leakage of polymethylmethaorylate into epidural or perivertebral veins. We have combined the procedure of intrathecal injection of contrast medium with vertebroplasty to better delineate spinal canal encroachment during injection when the posterior vertebral wall is compromised by myeloma.

Increased pedicle screw pullout strength with vertebroplasty augmentation in osteoporotic spines.

OBJECT: The authors conducted a biomechanical study to evaluate pedicle screw pullout strength in osteoporotic cadaveric spines. Nonaugmented hemivertebrae were compared with pressurized polymethylmethacrylate (PMMA)-augmented hemivertebrae. METHODS: Six formalin-fixed cadaveric thoracolumbar spines at least two standard deviations below the mean bone mineral density (BMD) for age were obtained. Radiographic and BMD studies were correlated to grades I, II, and III osteoporosis according to the Jekei scale. Each of the 21 vertebrae underwent fluoroscopic placement of 6-mm transpedicular screws with each hemivertebra serving as the control for the contralateral PMMA-augmented hemivertebra. Pedicle screws were then evaluated for biomechanical axial pullout resistance. Augmented hemivertebrae axial pullout forces were increased (p = 0.0005). The mean increase in pullout force was 181% for Grade I, 206% for Grade II, and 213% for Grade III osteoporotic spines. Augmented Grade I osteoporotic spines demonstrated axial pullout forces near those levels reported in the literature for nonosteoporotic specimens. Augmented Grade II osteoporotic specimens demonstrated increases to levels found in nonaugmented vertebrae with low-normal BMD. Augmented Grade III osteoporotic specimens had increases to levels equal to those found in nonaugmented Grade I vertebrae. CONCLUSIONS: Augmentation of osteoporotic vertebrae in PMMA-assisted vertebroplasty can significantly increase pedicle screw pullout forces to levels exceeding the strength of cortical bone. The maximum attainable force appears to be twice the pullout force of the nonaugmented pedicle screw for each osteoporotic grade.

Modification of a Braided Support Catheter into a Rapid Exchange System for Navigation of a Distal Protection Device through Significant Vascular Tortuosity.

Cerebral embolic protection devices (EPD) reduce the rate of periprocedural thromboembolic complications and are currently used in all carotid artery stenting (CAS) procedures. However, tortuous vascular anatomy of the internal carotid artery (ICA) may prevent navigation of distal EPDs, thereby leading to inadequate cerebral protection. We present a case in which significant tortuosity of the ICA distal to the stenotic lesion precluded navigation of currently available distal EPDs. During a CAS procedure, significant vascular tortuosity of the distal cervical ICA was noted which prevented navigation of currently available distal EPDs due to catheter kinking. In order to overcome this anatomic barrier, a novel rapid exchange catheter system (RECS) was created using a modified DAC 038 braided catheter through which a distal EPD and microguidewire were placed. This newly devised RECS allowed navigation of the distal EPD past the tortuous ICA bend and successful completion of the CAS procedure without periprocedural complications. We demonstrate that modification of currently available devices can, in select cases, effectively address cases of significant vascular tortuosity which limit the use of conventional distal EPDs.

Direct transcranial puncture for Onyx embolization of a cerebellar hemangioblastoma.

Intracranial hemangioblastomas are benign but hypervascular tumors, most commonly located in the cerebellum, which are difficult to resect without significant operative blood loss. While preoperative embolization may decrease the amount of operative bleeding, the vascular supply of cerebellar hemangioblastomas frequently precludes safe embolization by an endovascular route due to the risk of thromboembolic vertebrobasilar infarction. Direct puncture embolization overcomes many of the limitations of endovascular embolization but its safety and feasibility for intracranial tumors is unknown. We report a 48-year-old man who was diagnosed with a large cerebellar mass after presenting with headaches and gait ataxia. Based on diagnostic angiography, which demonstrated a highly vascular tumor supplied by the posterior inferior cerebellar and posterior meningeal arteries, we decided to embolize the tumor by a direct transcranial puncture approach. After trephinating the skull in a standard fashion, a catheter-needle construct, composed of an Echelon 10 microcatheter (ev3 Endovascular, Plymouth, MN, USA) placed into a 21-gauge spinal needle, was inserted into the tumor under biplanar angiographic guidance. Using continuous angiographic monitoring, 9cc of Onyx 34 (ev3 Endovascular) was injected through the catheter, resulting in 75% tumor devascularization without evidence of complications. The patient was taken directly to surgery where a gross total resection of the hemangioblastoma was achieved with an acceptable operative blood loss. At his 2 year follow-up, the patient was neurologically intact without neuroimaging evidence of residual tumor. We describe, to our knowledge, the first case of direct transcranial puncture for preoperative embolization of a cerebellar hemangioblastoma.

Endovascular treatment of recurrent intracranial aneurysms following previous microsurgical clipping with the Pipeline Embolization Device.

The treatment of intracranial aneurysms with microsurgical clipping is associated with a very low rate of recurrence. However, in cases of aneurysm recurrence after previous clipping, microsurgical dissection due to adhesions and fibrosis may be challenging, and it may be difficult to safely occlude the recurrent lesion without the risk of significant morbidity. Flow-diverting stents have drastically changed the landscape of endovascular neurosurgery. We present two patients with large, recurrent supraclinoid internal carotid artery (ICA) aneurysms which were previously clipped 17 and 23 years ago at outside institutions. Both recurrent lesions were treated with the Pipeline Embolization Device (PED; ev3 Endovascular, Irvine, CA, USA) without radiographic or clinical complications. In the first patient, the 15 mm aneurysm significantly decreased in size at 6 month angiographic follow-up. The 21 mm aneurysm in the second patient was completely occluded 7 months following PED treatment. The moderate degree of in-stent stenosis present on initial follow-up imaging resolved on angiography 11 months post-treatment. The management of recurrent aneurysms after clipping is sparsely reported in the literature due to its infrequent occurrence. In carefully selected cases, flow-diverting stents may be used for complex aneurysms of the distal ICA, even for those which have recurred following microsurgical clipping.

Balloon anchor technique for pipeline embolization device deployment across the neck of a giant intracranial aneurysm.

Treatment of giant intracranial aneurysms, via either surgical or endovascular approaches, is associated with a high level of technical difficulty as well as a high rate of treatment-related morbidity and mortality. Flow-diverting stents, such as the Pipeline embolization device (PED), have drastically altered the therapeutic strategies for the treatment of giant aneurysms. Gaining endovascular access using a microcatheter to the portion of the parent artery distal to the aneurysm neck is requisite for safe and effective stent deployment. Giant aneurysms are often associated with vascular tortuosity, which necessitates significant catheter support systems to enable maneuvering of PEDs across the aneurysm neck. This is also required in order to reduce the probability of stent herniation within giant aneurysms. We report on a case of a giant supraclinoid internal carotid artery (ICA) aneurysm which was treated successfully with a PED utilizing a balloon anchor technique to facilitate direct microcatheter access across the aneurysm neck.

Persistent trigeminal artery: in situ thrombosis and associated perforating vessel infarction.

We report a patient with progressive brainstem infarction despite medical therapy. The patient was transferred to our institution for potential angioplasty of basilar stenosis. Imaging review demonstrated persistent trigeminal artery in situ thrombosis and associated perforating vessel infarction. Persistent trigeminal arteries are commonly associated with an atretic basilar artery and interventional treatment can result in significant morbidity and mortality.

Treatment of type II endoleak using Onyx with long-term imaging follow-up.

PURPOSE: The purpose of our study is to report our experience with the use of an ethylene vinyl alcohol copolymer (Onyx) in an off-label fashion for the treatment of type II endoleak after endovascular repair of the thoracic (TEVAR) and abdominal (EVAR) aorta. METHODS: A retrospective review of patients with type I and/or II endoleak treated with Onyx was performed. Data regarding the technical, clinical, and imaging outcomes were collected. Technical success was defined as decreased or eliminated endoleak on the first imaging follow-up. Clinical success was defined as unchanged or decreased aneurysm sac size on subsequent follow-up. RESULTS: Eighteen patients (15 male, 3 female) with a mean age of 79 years (range 69-92) met inclusion criteria (16 abdominal aortic aneurysm, 2 thoracic aortic aneurysm). Sixteen patients had type II endoleak, and 2 had complex type II endoleak with a type I component. The interval between endograft placement and treatment was a mean of 30 months. Direct sac treatment approach was used in 13 patients; transarterial approach was used in 3 patients. Seven patients required the use of coils, N-butyl cyanoacrylate glue, or Amplatzer vascular plugs. The average volume of Onyx used per treatment was 5.6 mL (range 2.5-13). Duration of imaging follow-up was 0.75-72.5 months (mean 32.8). Sixteen of 18 (88.9 %) patients had initial technical and clinical success. Two of 18 patients (11.1 %) were initial technical failures, and 1 remained a failure despite a second treatment and attempted surgical ligation. Eight of 18 (44.4 %) of patients eventually required a second intervention, 5 (27.8 %) of them due to delayed clinical failure. Complications included 1 psoas hematoma, 1 transient L2 nerve paresis, and 1 intraperitoneal Onyx leak; all of these were without clinical sequelae. CONCLUSION: Onyx with or without coil/glue/Amplatzer plug embolization is safe and useful in the treatment of type II endoleak after TEVAR and EVAR. However, long-term clinical and imaging follow-up is needed for early detection and management of recurrence of the primary endoleak or the development of new, secondary endoleaks or enlargement of the aneurysm sac.