Onyx embolization of a ruptured anterior inferior cerebellar artery in a neonate.

Aneurysmal subarachnoid hemorrhage (SAH) is rare in neonates. The authors present a unique report of a neonate with SAH from anterior inferior cerebellar artery (AICA) aneurysm rupture that was successfully treated with Onyx embolization. This case report demonstrates the utility of Onyx embolization for posterior circulation aneurysms in neonates and the successful management of SAH in this population.

Isolated Internal Carotid Artery Thrombus and Cerebral Infarction in a Patient with Necrotizing Pancreatitis: Case Report.

Isolated internal carotid artery (ICA) thrombus in the absence of underlying atherosclerotic disease is a rare entity. We report a case of a patient presenting with right arm weakness, slurred speech, and altered mental status in the setting of acute on chronic pancreatitis. The patient was found to have scattered left cerebral hemisphere cortical infarctions, and catheter angiography confirmed the presence of intraluminal left ICA thrombus, with no evidence of atherosclerotic disease in the cervical or intracranial vasculature. Further workup also demonstrated the presence of anemia of chronic disease. The patient was initiated on anticoagulation, and follow-up imaging demonstrated a complete resolution of the left ICA thrombus. In the reported case, coagulopathy in the setting of acute on chronic pancreatitis was presumably the primary etiology. Anemia of chronic disease, related to a proinflammatory state, may also play a contributory role.

Utility of Screening for Cerebral Vasospasm Using Digital Subtraction Angiography.

BACKGROUND AND PURPOSE: Cerebral arterial vasospasm (CVS) is a common complication of aneurysmal subarachnoid hemorrhage strongly associated with neurological deterioration and delayed cerebral ischemia (DCI). The utility of screening for CVS as a surrogate for early detection of DCI, especially in patients without clinical signs of DCI, remains uncertain. METHODS: We performed a retrospective analysis of 116 aneurysmal subarachnoid hemorrhage patients who underwent screening digital subtraction angiography to determine the association of significant CVS and subsequent development of DCI. Patients were stratified into 3 groups: (1) no symptoms of DCI before screening, (2) ≥1 episodes of suspected DCI symptoms before screening, and (3) unable to detect symptoms because of poor examination. RESULTS: Patients asymptomatic before screening had significantly lower rates of CVS (18%) compared with those with transient symptoms of DCI (60%; P<0.0001). None of the 79 asymptomatic patients developed DCI after screening, regardless of digital subtraction angiography findings, compared with 56% of those with symptoms (P<0.0001). Presence of CVS was significantly associated with DCI in those with transient symptoms and in those whose examinations did not permit clear assessment (odds ratio 16.0, 95% confidence interval 2.2-118.3, P=0.003). CONCLUSIONS: Patients asymptomatic before screening have low rates of CVS and seem to be at negligible risk of developing DCI. Routine screening of asymptomatic patients seems to have little utility. Screening may still be considered in patients with possible symptoms of DCI or those with examinations too poor to clinically detect symptoms because finding CVS may be useful for risk stratification and guiding management.

Amyloid-ß efflux from the central nervous system into the plasma.

OBJECTIVE: The aim of this study was to measure the flux of amyloid-ß (Aß) across the human cerebral capillary bed to determine whether transport into the blood is a significant mechanism of clearance for Aß produced in the central nervous system (CNS). METHODS: Time-matched blood samples were simultaneously collected from a cerebral vein (including the sigmoid sinus, inferior petrosal sinus, and the internal jugular vein), femoral vein, and radial artery of patients undergoing inferior petrosal sinus sampling. For each plasma sample, Aß concentration was assessed by 3 assays, and the venous to arterial Aß concentration ratios were determined. RESULTS: Aß concentration was increased by ∼7.5% in venous blood leaving the CNS capillary bed compared to arterial blood, indicating efflux from the CNS into the peripheral blood (p < 0.0001). There was no difference in peripheral venous Aß concentration compared to arterial blood concentration. INTERPRETATION: Our results are consistent with clearance of CNS-derived Aß into the venous blood supply with no increase from a peripheral capillary bed. Modeling these results suggests that direct transport of Aß across the blood-brain barrier accounts for ∼25% of Aß clearance, and reabsorption of cerebrospinal fluid Aß accounts for ∼25% of the total CNS Aß clearance in humans. Ann Neurol 2014;76:837-844.

Microsurgical confirmation of perforating arteries arising from the fundus of a posterior communicating artery aneurysm.

Perforating arteries rarely project from the fundus of an aneurysm. We present the case of a 35-year-old woman who was found to have a right posterior communicating artery (PCOM) aneurysm via catheter angiography. Superselective microcatheter angiography revealed that perforating arteries arose from the aneurysm fundus that supplied the anterolateral thalamus. Microsurgical exploration confirmed several small perforating arteries arising from the aneurysm dome as well as an atretic distal PCOM artery. Given the complex anatomy, the lesion was unsuitable for clipping. We propose that this aneurysm represents a developmental variant whereby the proximal PCOM artery becomes atretic and terminates in PCOM perforators. The video can be found here: http://youtu.be/iDcp9fsDjq4.

Surgical Revascularization in North American Adults with Moyamoya Phenomenon: Long-Term Angiographic Follow-up.

BACKGROUND: North American and Asian forms of moyamoya have distinct clinical characteristics. Asian adults with moyamoya are known to respond better to direct versus indirect revascularization. It is unclear whether North American adults with moyamoya have a similar long-term angiographic response to direct versus indirect bypass. METHODS: A retrospective review of surgical revascularization for adult moyamoya phenomenon was performed. Preoperative and postoperative cerebral angiograms underwent consensus review, with degree of revascularization quantified as extent of new middle cerebral artery (MCA) territory filling. RESULTS: Late angiographic follow-up was available in 15 symptomatic patients who underwent 20 surgical revascularization procedures. In 10 hemispheres treated solely with indirect arterial bypass, 3 had 2/3 revascularization, 4 had 1/3 revascularization, and 3 had no revascularization of the MCA territory. In the 10 hemispheres treated with direct arterial bypass (8 as a stand-alone procedure and 2 in combination with an indirect procedure), 2 had complete revascularization, 7 had 2/3 revascularization, and 1 had 1/3 revascularization. Direct bypass provided a higher rate of "good" angiographic outcome (complete or 2/3 revascularization) when compared with indirect techniques (P = .0198). CONCLUSIONS: Direct bypass provides a statistically significant, more consistent, and complete cerebral revascularization than indirect techniques in this patient population. This is similar to that reported in the Asian literature, which suggests that the manner of presentation (ischemia in North American adults versus hemorrhage in Asian adults) is likely not a contributor to the extent of revascularization achieved after surgical intervention.

In-hospital imaging utilization after elective endovascular brain aneurysm treatment: a surrogate metric for the value of hospitalization.

OBJECTIVE: Despite the adoption of same-day outpatient surgical procedures in some specialties, it remains common practice to admit patients for monitoring after elective endovascular treatment of brain aneurysms to monitor for complications. The necessity of such monitoring has not been fully characterized. Here, the authors reviewed the utilization of imaging during posttreatment hospitalization, a surrogate measure for workup of suspected complications requiring hospital resources, to infer the value of inpatient monitoring after endovascular aneurysm treatment. METHODS: Clinical and angiographic data from eligible patients were retrospectively assessed for demographic characteristics, imaging indications, timing of imaging, and imaging findings. Patients were included if they underwent elective endovascular brain aneurysm treatment, and patients were excluded if significant intraprocedural complications occurred. The recorded imaging modalities included CT, MRI, catheter-based imaging, and ultrasound; plain radiographs were excluded. Multivariable logistic regression analysis was performed to identify predictors of the need for posttreatment imaging. RESULTS: In total, 1229 elective endovascular procedures for brain aneurysm treatment were included. Patients underwent imaging before discharge in 13.4% (165/1229) of cases, with significant findings in 5.0% (61/1229) of cases. The median (interquartile range) time to first posttreatment imaging was 13.2 (4.2-22.8) hours. The need for imaging during posttreatment hospitalization was positively associated with larger aneurysm size (p < 0.05) and negatively associated with underlying cardiovascular disease (p < 0.05). CONCLUSIONS: More than 1 in 8 patients who underwent elective endovascular brain aneurysm treatment required imaging during posttreatment hospitalization, most within the first 24 hours, and 1 in 20 had significant findings. These results suggest the importance of short-term hospitalization after elective endovascular aneurysm treatment.

Comparison of Enterprise with Neuroform stent-assisted coiling of intracranial aneurysms.

OBJECTIVE: The Enterprise stent is the first closed-cell stent designed to treat wide-necked intracranial aneurysms. Advantages of the design can include improvement in keeping coils within an aneurysm and the ability of the stent to be recaptured. We compared the technical and clinical complications of the Enterprise stent with the open-cell Neuroform stent, its primary alternative. SUBJECTS AND METHODS: Patients undergoing Enterprise and Neuroform stent-assisted aneurysm coiling were enrolled in prospective registries starting in March 2007 and February 2003, respectively. All consecutive patients through December 2011 were included. Deployment success and difficulty, stent movement and misplacement, and procedural complications were compared. RESULTS: Enterprise deployment success was high (108 of 115 attempts, 93.9%) with 102 aneurysms receiving a stent compared with Neuroform (173 of 214 attempts, 80.8%, p = 0.001) with 163 aneurysms. Enterprise was easier to deploy (1.7% vs 15.9% difficult deployment, p < 0.0001). There were no significant differences in the rates of stent movement, misplacement, or symptomatic hemorrhage. Symptomatic thromboembolic events, however, were more frequent with the Enterprise stent (8.7% vs 1.4%, p = 0.0021). The Enterprise stent enabled treatment of 10 additional aneurysms that could not be treated with Neuroform and had a higher rate of immediate aneurysm occlusion (87.3% vs 73.0%, p = 0.0058). CONCLUSION: Enterprise was easier to deploy and enabled treatment of additional aneurysms; however, there were more thromboembolic complications. On the basis of these findings, we prefer to use the Neuroform stent first and rely on the Enterprise stent as an easy-to-deliver backup for stent-assisted coiling.

Endovascular treatment of dural arteriovenous fistulas involving the vein of Galen: a single-center cohort and meta-analysis.

BACKGROUND: Dural arteriovenous fistulas (dAVFs) draining into the vein of Galen (VoG) are complex lesions that often necessitate treatment to minimize the risk of rupture and relieve symptoms. These lesions can be treated with open surgical resection, radiosurgery, or endovascular embolization. Unfortunately, endovascular treatment of dAVFs involving the VoG has not been robustly assessed across large patient cohorts. To meet this need, we performed a retrospective review of dAVFs involving the VoG at our center, and included these in a meta-analysis to identify the safety and efficacy of endovascular embolization, as well as describing current treatment trends for this disease. METHODS: Consecutive patients with dAVFs involving the VoG treated at a single center were identified from a prospective database and retrospectively reviewed. A literature search was conducted with defined search criteria, and eligible studies were included alongside our cohort in a meta-analysis. Rates of complete dAVF treatment and clinical complications were pooled across studies with a random effects model and reported with a 95% CI. RESULTS: Five dAVFs involving the VoG were treated endovascularly at our center during the study period. In this series, 80% of treatments led to complete occlusion of the fistula while no patients had clinical complications. Onyx was used for all treatments. In our meta-analysis, the overall rate of complete occlusion was 72.0% (95% CI 59.8% to 84.1%) and the overall rate of clinical complications was 10.0% (95% CI 4.7% to 15.3%). CONCLUSIONS: Endovascular approaches for dAVFs involving the VoG are technically feasible, but carry a risk of clinical complications. Future work should identify optimal endovascular embolic agents.

A review of technological innovations leading to modern endovascular brain aneurysm treatment.

Tools and techniques utilized in endovascular brain aneurysm treatment have undergone rapid evolution in recent decades. These technique and device-level innovations have allowed for treatment of highly complex intracranial aneurysms and improved patient outcomes. We review the major innovations within neurointervention that have led to the current state of brain aneurysm treatment.

Effect of Intravenous Thrombolysis on Clot Survival during Mechanical Thrombectomy in Acute Large Vessel Occlusion Strokes.

BACKGROUND: The benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO) stroke is uncertain. Conventional metrics of final modified thrombolysis in cerebral ischemia (mTICI) score and 90-d modified Rankin Scale may be insensitive to IVT effects on procedural complexity and duration. OBJECTIVE: To study the effect of IVT prior to MT on clot survival. METHODS: We performed a single-center retrospective analysis of 257 acute stroke patients with LVO undergoing MT and analyzed the effect of IVT prior to MT using a novel, pass-by-pass clot survival methodology. RESULTS: The use of IVT was associated with a significantly lower number of passes to attain mTICI 2B or greater (P = .002) or mTICI 3 (P = .039) reperfusion. The number of patients who achieved mTICI 2B or greater after the first pass was significantly higher in the IVT group (P = .003). This increased rate of reperfusion persisted into subsequent passes. CONCLUSION: IVT prior to MT reduces the number of thrombectomy passes required to achieve mTICI 2B or mTICI 3 reperfusion. This information should be considered as the merits of IVT prior to MT are debated.

Treatment of pediatric intracranial aneurysms: case series and meta-analysis.

BACKGROUND: There are limited outcome data to guide the choice of treatment in pediatric patients with cerebral aneurysms. OBJECTIVE: To describe our institutional experience treating pediatric patients with cerebral aneurysms and to conduct a meta-analysis of available studies to provide the best current evidence on treatment related outcomes. METHODS: We identified pediatric patients with cerebral aneurysms evaluated or treated at our institution using a comprehensive case log. We also identified studies to include in a meta-analysis through a systematic search of Pubmed, SCOPUS, EMBASE, and the Cochrane Database of Systematic Reviews. As part of both the local analysis and meta-analysis, we recorded patient characteristics, aneurysm characteristics, management, and outcomes. Statistical analysis was performed using Fisher's exact test and the two tailed Student's t test, as appropriate. RESULTS: 42 pediatric patients with 57 aneurysms were evaluated at our institution, and treatment specific outcome data were available in 560 patients as part of our meta-analysis. Endovascular and surgical treatments yielded comparable rates of favorable outcome in all children (88.3% vs 82.7%, respectively, P=0.097), in children with ruptured aneurysms (75% vs 83%, respectively, P=0.357), and in children with unruptured aneurysms (96% vs 97%, respectively, P=1.000). CONCLUSION: Endovascular and surgical treatment yield comparable long term clinical outcomes in pediatric patients with cerebral aneurysms.

Pipeline Embolization of Vertebrobasilar Aneurysms-A Multicenter Case Series.

BACKGROUND: The Pipeline Embolization Device (PED) has been increasingly used for the treatment of posterior circulation aneurysms. The purpose of the present study was to examine the clinical and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. METHODS: We performed a retrospective review of vertebrobasilar aneurysms treated with the PED at 4 high-volume neurovascular centers. Patient, aneurysm, and procedural data were collected, including perioperative and delayed complications. Aneurysm occlusion on follow-up imaging studies was defined as complete (100%), near-complete (>90%), or incomplete (<90%) occlusion. RESULTS: The cohort included 35 patients with 37 vertebrobasilar aneurysms who underwent 36 treatment sessions. Of the 35 patients, 10 were men (29%), and the mean patient age was 54.1 years (range, 32-75). Eight patients (23%) underwent urgent treatment because of a ruptured aneurysm (n = 6), brainstem perforator stroke (n = 1), or post-traumatic pseudoaneurysm (n = 1). Of the 37 aneurysms, 22 arose from the vertebral artery (59%) and 15 from the basilar artery (41%). Also, 19 were saccular aneurysms (51%), with a mean size of 7.7 mm (range, 1.7-38.0); 17 were fusiform aneurysms (46%), with a mean size of 11.0 mm (range, 4.3-34); and 1 was a 2.9-mm blister aneurysm. The overall procedural complication rate was 14% (5 of 36), including 3 neurologically symptomatic complications. At a mean follow-up period of 14 months (range, 3-59), 24 of 34 aneurysms (71%) were completely occluded and 29 of 34 (85%) were completely or near-completely occluded. CONCLUSION: Our results show that Pipeline embolization of vertebrobasilar aneurysms is associated with acceptable occlusion and complication rates.

Rotational vertebrobasilar insufficiency due to dynamic compression of the dominant vertebral artery by the thyroid cartilage and occlusion of the contralateral vertebral artery at C1-2 level.

BACKGROUND: Vertebrobasilar insufficiency caused by head rotation is an uncommon event. The mechanism is obstruction of the vertebral artery resulting in flow limitation or, less frequently, thromboembolism. CASE DESCRIPTION: A 41-year-old male developed dizziness and light-headedness during chiropractic manipulation when his head was turned to the extreme right position. Computed tomography angiography (CTA) of the neck and selective digital subtraction angiography (DSA) of the vertebral arteries revealed that when the patient turned his head to the extreme right position the dominant right vertebral artery was compressed between the posterior aspect of the thyroid cartilage and anterior aspect of the right transverse process of C6 resulting in focal stenosis, while the left vertebral artery is severely compressed with significant flow limitation at the level of C1-2. Because the patient was healthy and asymptomatic, conservative management was adopted. At the 9-month follow-up visit the patient was asymptomatic and able to compensate for his problem avoiding turning his head to the extreme right position. CONCLUSIONS: We present an uncommon case of rotational vertebrobasilar insufficiency (VBI) where the dominant vertebral artery has an anomalous course compressed by the thyroid cartilage at C6 level, associated with contralateral vertebral artery rotational stenosis at C1-2. The patient was successfully managed conservatively.

Direct puncture Onyx embolization of a large calvarial metastasis with intracranial extension: Case report.

We report a case of renal cell carcinoma (RCC) metastasis to the calvarium and describe a strategy for percutaneous embolization of hypervascular calvarial tumors with intracranial extension. An elderly patient with history of RCC presented with left-sided weakness. Imaging studies showed a large right frontoparietal calvarial mass with intra- and extracranial extension. The tumor was devascularized by direct puncture tumor embolization using Onyx 18, allowing subsequent operative resection without significant blood loss or the need for flap reconstruction of the scalp. Compared to more common endovascular approaches, direct-needle puncture embolization of transcalvarial masses may offer lower risk of injury to scalp vessels and underlying brain parenchyma.

Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke.

OBJECTIVE: Shorter time from symptom onset to treatment is associated with improved outcomes in patients who undergo mechanical thrombectomy for treatment of acute ischemic stroke due to emergent large vessel occlusion. In this work, we detail pre-thrombectomy process improvements in a multi-hospital network and report the effect on door-to-puncture time in patients undergoing mechanical thrombectomy. PATIENTS AND METHODS: A streamlined workflow was adopted to minimize door-to-puncture time. Key features of this workflow included rapid and concurrent clinical and radiological evaluation with point-of-care image interpretation, pre-transfer IV thrombolysis and CTA for transferred patients, immediate transport to the angiography suite potentially before neurointerventional radiology team arrival, and minimalist room setup. Door-to-puncture time was measured prospectively and analyzed retrospectively for 78 consecutive patients treated between January 2015 and December 2015. Statistical analysis was performed using the F-test on individual coefficients of a linear regression model. RESULTS: From quarter 1 to quarter 4, the number of thrombectomies performed increased by 173% (11 patients to 30 patients, p = 0.002), and there was a significant increase in the proportion of transferred patients that underwent pre-transfer CTA (p = 0.04). During this interval, overall median door-to-puncture time decreased by 74% (147 min to 39 min, p < 0.001); this decrease was greatest in transferred patients with pre-transfer CTA (81% decrease, 129 min to 25 min, p < 0.001) and smallest in patients presenting directly to the emergency department (52% decrease, 167 min to 87 min, p < 0.001). CONCLUSION: Simple workflow improvements to streamline in-hospital triage and perform critical workup at transferring hospitals can produce reductions in door-to-puncture time.

Endovascular Treatment of Posterior Cerebral Artery Aneurysms With Flow Diversion: Case Series and Systematic Review.

BACKGROUND: Flow diversion of posterior cerebral artery (PCA) aneurysms has not been widely reported, possibly owing to concerns regarding parent vessel size and branch vessel coverage. OBJECTIVE: To examine the safety and effectiveness of PCA aneurysm flow diverter treatment. METHODS: Retrospective review of PCA aneurysms treated with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland) at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes. Systematic review of the literature identified published reports of PCA aneurysms treated with flow diversion. Rates of aneurysm occlusion and complications were calculated, and outcomes of saccular and fusiform aneurysm treatments were compared. RESULTS: Ten PCA aneurysms in 9 patients were treated with the PED. There were 2 intraprocedural thromboembolic events (20%), including 1 symptomatic infarction and 1 delayed PED thrombosis. Eight of 10 patients returned to or improved from their baseline functional status. Complete aneurysm occlusion with parent vessel preservation was achieved in 75% (6/8) of cases at mean follow-up of 16.7 mo. Eleven of 12 (92%) major branch vessels covered by a PED remained patent. Including the present study, systematic review of 15 studies found a complete aneurysm occlusion rate of 88% (30/34) and complication rate of 26% (10/38), including 5 symptomatic ischemic strokes (13%; 5/38). Fusiform aneurysms more frequently completely occluded compared with saccular aneurysms (100% vs 70%; P = .03) but were associated with a higher complication rate (43% vs 9%; P = .06). CONCLUSION: The safety and effectiveness profile of flow diverter treatment of PCA aneurysms may be acceptable in select cases.

Techniques of carotid angioplasty and stenting.

Carotid angioplasty and stenting (CAS) is an alternative technique to restore a normal lumen for patients who are at high risk for adverse effects with carotid endarterectomy (CEA). CAS has been shown to be of benefit to several groups of patients who have carotid disease and who ordinarily are excluded from many CEA trials. Government payors have approved embolic protection devices (EPDs) and stents for the now reimbursable procedure. In fact, the Centers for Medicare and Medicaid Services are now mandating use of the EPDs in CAS to issue payment. The prudent practitioner will carefully select the patients for CAS with EPD and CEA, so that patients will have the safest opportunity to avoid the devastating effects of cerebrovascular accidents.

Technique for intracranial balloon and stent-assisted angioplasty for atherosclerotic stenosis.

Dilation of stenoses of the major intracranial arteries is now technically possible in many cases. Using proper precautions, most procedures can be performed without complications today, but the safety margin will likely be improved with refinement of current devices and the introduction of new devices made specifically for this indication. Early experience with these techniques is promising for lowering the risk for recurrent ischemic events in patients who have symptomatic intracranial arterial stenosis refractory to medical therapy. This article describes the steps taken to perform transluminal balloon angioplasty and stent-assisted angioplasty for intracranial atherosclerotic stenosis, from patient preparation through follow-up, including procedural steps and device selection.