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BACKGROUND: The delivery of neuroendovascular devices requires a robust proximal access platform. This demand has previously been met with a 6Fr long sheath (8Fr guide) that is placed in the proximal internal carotid artery (ICA) or vertebral artery segments. We share our experience with the first 0.088 inch 8Fr guide catheter designed for direct intracranial access. METHODS: We retrospectively reviewed a prospectively maintained IRB-approved institutional database of the senior authors to identify all cases where the TracStar Large Distal Platform (LDP) was positioned within the intracranial vasculature, defined as within or distal to the petrous ICA, vertebral artery (V3) segments, or transverse sinus. Technical success was defined as safe placement of the TracStar LDP within or distal to the described distal vessel segments with subsequent complication-free device implantation. RESULTS: Over the 41-month study period from January 2020 to June 2023, 125 consecutive cases were identified in whom the TracStar LDP was navigated into the intracranial vasculature for triaxial delivery of large devices, 0.027 inch microcatheter and greater, for aneurysm treatment (n=108, 86%), intracranial angioplasty/stenting (n=15, 12%), and venous sinus stenting (n=2, 1.6%). All cases used a direct select catheter technique for initial guide placement (no exchange). Posterior circulation treatments occurred in 14.4% (n=18) of cases. Technical success was achieved in 100% of cases. No vessel dissections occurred in any cases. CONCLUSION: The TracStar LDP is an 0.088 inch 8Fr guide catheter that can establish direct intracranial access with an acceptable safety profile. This can be achieved in a wide range of neurointerventional cases with a high rate of technical success.
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Formation of a carotid free-floating thrombus (CFFT) is a rare and life-threatening condition without an optimal management plan. A 78-year-old woman with a history of prior right internal carotid artery (ICA) mechanical thrombectomy and antiplatelet noncompliance presented with transient ischemic attacks secondary to a recurrent CFFT in the right ICA. Given her symptoms and recurrent CFFT, endovascular mechanical thrombectomy was performed. A balloon guide-catheter (BGC) and a Zoom 88 distal access catheter were brought into the right distal common carotid artery and proximal ICA bulb, respectively. Three 0.021-inch microcatheters, each loaded with a unique stentriever, were navigated beyond the thrombus into the upper cervical ICA and deployed in a bouquet fashion. The BGC was inflated to achieve flow arrest, and the Zoom 88 aspiration catheter was tracked over the three bouquet stentrievers to ingest the thrombus. Follow-up angiography demonstrated recanalization of the proximal cervical ICA without evidence of residual thrombus. Twenty-four-hour postoperative computed tomography imaging did not reveal any evidence of new infarction. The patient was discharged home with an intact neurological examination, compliant on aspirin and apixaban. We demonstrate a novel technique utilizing a large-bore catheter with a triple stentriever "bouquet" to thrombectomize a CFFT.
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BACKGROUND: Endovascular embolization of the middle meningeal artery (MMA) has emerged as an adjunctive and stand-alone modality for the management of chronic subdural hematomas (cSDH). We report our experience utilizing proximal MMA coil embolization to augment cSDH devascularization in MMA embolization. METHODS: MMA embolization cases with adjunctive proximal MMA coiling were retrospectively identified from a prospectively maintained IRB-approved database of the senior authors. RESULTS: Of the 137 cases, all patients (n = 89, 100%) were symptomatic and underwent an MMA embolization procedure for cSDH. 50 of the patients underwent bilateral embolizations, with 53% (n = 72) for left-sided and 47% (n = 65) for right-sided cSDH. The anterior MMA branch was embolized in 19 (14%), posterior in 16 (12%), and both in 102 (74.5%) cases. Penetration of the liquid embolic to the contralateral MMA or into the falx was present in 38 (28%) and 31 (23%) cases, respectively, and 46 (34%) cases had ophthalmic or petrous collateral (n = 41, 30%) branches. MMA branches coiled include the primary trunk (25.5%, n = 35), primary and anterior or posterior MMA trunks (20%, n = 28), or primary with the anterior and posterior trunks (54%, n = 74). A mild ipsilateral facial nerve palsy was reported, which remained stable at discharge and follow-up. Absence of anterograde flow in the MMA occurred in 137 (100%) cases, and no cases required periprocedural rescue surgery for cSDH evacuation. The average follow-up length was 170 ± 17.9 days, cSDH was reduced by 4.24 ± 0.5(mm) and the midline shift by 1.46 ± 0.27(mm). Complete resolution was achieved in 63 (46.0%) cases. CONCLUSION: Proximal MMA coil embolization is a safe technique for providing additional embolization/occlusion of the MMA in cSDH embolization procedures. Further studies are needed to evaluate the potential added efficacy of this technique.
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BACKGROUND: Flow diversion (FD) embolization of intracranial cerebral aneurysms is an increasingly common modality where treatment success depends on adequate vessel wall apposition of the device. This study aimed to investigate off-label use of the Comaneci device for augmenting vessel wall apposition in post-deployed flow diversion stents (FDS). METHODS: Over a 20- month period, all FD cases for the treatment of internal carotid artery (ICA) aneurysms were reviewed. Cases in which the Comaneci device was used to augment vessel wall apposition were analyzed. Data including patient demographics, case characteristics, and procedural outcomes were collected and analyzed as counts. RESULTS: From a total of 74 ICA FD cases, the Comaneci device was used to improve vessel wall apposition in 22 cases (29.7%) . Of these cases, 91% were female with a mean patient age of 64.9±11.3 years, and an average aneurysm size of 4.5±2.5 mm. Comaneci device deployment and retrieval was successful in all (100%) cases, with an average fluoroscopy time of 27.3±7.8 min, an average contrast usage of 25.8±13.2 mL, and an average radiation exposure of 915.1±320.8 mGy. Only two cases (9%) required subsequent balloon angioplasty after Comaneci deployment to improve vessel wall apposition throughout the FDS. CONCLUSION: Our experience with this technique demonstrates the feasibility of using the Comaneci device for augmentation of FDS vessel wall apposition with 100% success in the deployment and retrieval of the Comaneci device.
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BACKGROUND: COVID-19 has impacted neurosurgical care around the world. But reports describing patient admission trends during the pandemic have provided limited time frames and diagnoses. The purpose of this paper was to analyze the impact of COVID-19 on neurosurgical care provided to our emergency department during the outbreak. METHODS: Patient admission data were collected based on a list of 35 ICD-10 codes, which were placed into 1 of 4 categories: head and spine trauma ("Trauma"), head and spine infection ("Infection"), degenerative spine ("Degenerative"), and subarachnoid hemorrhage/brain tumor ("Control"). Emergency department (ED) consultations to the Neurosurgery Department were collected from March 2018 to March 2022, representing 2 years before COVID and 2 years of pandemic. We hypothesized that Control cases would remain stable throughout the 2 time periods while Trauma and Infection would decrease. Because of widespread clinic restrictions, we postulated Degenerative (spine) cases presenting to the ED would increase. RESULTS: During the first 2 years of the COVID pandemic, Neurosurgical Trauma and Degenerative ED patients decreased compared with prepandemic levels, while Cranial and Spinal infections increased and continued to do so during the pandemic period studied. Brain tumors and subarachnoid hemorrhages (Control cases) did not change in a significant way throughout the 4-year analysis. CONCLUSIONS: The COVID pandemic significantly altered the demographics of our Neurosurgical ED patient population and continues to do so.
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BACKGROUND: Spinal hematomas are a rare entity with broad etiologies, which stem from idiopathic, tumor-related, and vascular malformation etiologies. Less common causes include traumatic blunt nonpenetrating spinal hematomas with very few cases being reported. In the present manuscript presents a case report and review of the literature of a rare traumatic entity of a cervical subarachnoid hematoma in association with Brown-Séquard syndrome in a patient on anticoagulants. Searches were performed on PubMed and Embase for specific terms related. OBSERVATIONS: A well-documented case of an 83-year-old female taking anticoagulants with traumatic cervical subarachnoid hematoma presenting as Brown-Séquard syndrome was reported. Six similar cases were identified, scrutinized, and analyzed in the literature review. LESSONS: Traumatic blunt nonpenetrating cervical spine subarachnoid hematomas are a rare entity that can happen more specifically in anticoagulant users and in patients with arthritic changes and stenosis of the spinal canal. Rapid neurological deterioration and severe disability warrant early aggressive surgical treatment. This report has the intention to record this case in the medical literature for registry purposes.