Triple therapy versus dual-antiplatelet therapy for dolichoectatic vertebrobasilar fusiform aneurysms treated with flow diverters.

BACKGROUND: Dolichoectatic vertebrobasilar fusiform aneurysms (DVBFAs) have poor natural history when left untreated and high morbimortality when treated with microsurgery. Flow diversion (FD) with dual-antiplatelet therapy (DAPT) is feasible but carries high risk of perforator occlusion and progression of brainstem compression. Elaborate antithrombotic strategies are needed to preserve perforator patency while vessel remodeling occurs. We compared triple therapy (TT (DAPT plus oral anticoagulation)) and DAPT alone in patients with DVBFAs treated with FD. METHODS: Retrospective comparison of DAPT and TT in patients with DVBFAs treated with FD at eight US centers. RESULTS: The groups (DAPT=13, TT=14) were similar in age, sex, clinical presentation, baseline disability, and aneurysm characteristics. Radial access use was significantly higher in the TT group (71.4% vs 15.3%; P=0.006). Median number of flow diverters and adjunctive coiling use were non-different between groups. Acute ischemic stroke rate during the oral anticoagulation period was lower in the TT group than the DAPT group (7.1% vs 30.8%; P=0.167). Modified Rankin Scale score decline was significantly lower in the TT group (7.1% vs 69.2%; P=0.001). Overall rates of hemorrhagic complications (TT, 28.6% vs DAPT, 7.7%; P=0.162) and complete occlusion (TT, 25% vs DAPT, 54.4%; P=0.213) were non-different between the groups. Rate of moderate-to-severe disability at last follow-up was significantly lower in the TT group (21.4% vs 76.9%; P=0.007). CONCLUSIONS: Patients with DVBFAs treated with FD in the TT group had fewer ischemic strokes, less symptom progression, and overall better outcomes at last follow-up than similar patients in the DAPT group.

Brain Bypass Surgery for Complex Middle Cerebral Artery Aneurysms: Evolving Techniques, Results, and Lessons Learned.

OBJECTIVE: To analyze a consecutive series of patients with middle cerebral artery (MCA) aneurysms who needed an adjunctive cerebral revascularization procedure to achieve aneurysm occlusion with preservation of flow through all MCA branches. METHODS: A total of 42 patients with 43 MCA aneurysms underwent 52 bypass procedures over 13 years. The location of the aneurysm were M1 trunk, M1 bifurcation, M2 and beyond. The bypasses performed included intracranial bypasses (resection with end to end anastomosis, end to side implantation, side to side anastomosis, and short interposition graft), extraintracranial bypasses (superficial temporal to middle cerebral artery anastomosis, and radial artery bypass graft, or saphenous vein graft), double bypasses, Y-grafts, and combined techniques. RESULTS: Forty-two of 43 aneurysms (98%) had patent bypasses at long-term follow-up. All 43 aneurysms were completely occluded at last follow-up. Six patients (14%) developed strokes related to the surgical treatment. At last follow-up, 36 patients had a modified Rankin score of 0-2, 5 patients had modified Rankin score 3-5, and 1 died. In this series, 31 (73.8%) patients improved, 8 (19%) patients had same functional status, and 3 (7.2%) patients deteriorated, including 1 patient who expired due to sepsis. The mean clinical follow-up duration was 39.3 months (0.4-124 months) and the mean radiological follow-up was 37 months (0.4-134 months). CONCLUSIONS: Cerebral revascularization is an important adjunct for treating MCA aneurysms and can be done safely. The article provides the insights we gained by rising through the learning curve.

Endovascular therapy of wake-up strokes in the modern era of stent retriever thrombectomy.

BACKGROUND: Endovascular treatment of wake-up strokes (WUS) has been previously described, mostly with the use of pharmacological thrombolysis or first generation thrombectomy devices. OBJECTIVE: To describe outcomes of WUS treated with modern endovascular therapy since the Food and Drug Administration approval of stent retrievers, and to identify predictors of good clinical outcome in this population of stroke patients. METHODS: We performed a multicenter retrospective analysis of consecutive patients with WUS who underwent thrombectomy with stent retrievers Trevo (Stryker, Kalamazoo, Michigan, USA) and Solitaire FR (Covidien, Irvine, California, USA), or primary aspiration thrombectomy. We correlated favorable clinical outcomes with demographic, clinical, and technical characteristics. RESULTS: 52 patients were included in this study; 46 (88%) cases were treated with stent retrievers and 6 (12%) were treated with primary aspiration thrombectomy alone. Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b/3) was achieved in 36 (69%) patients. Favorable clinical outcome at 3 months, defined as a modified Rankin Scale score of 0-2, was achieved in 25 (48%) patients. Duration of intervention <30 min and its success, defined as TICI 2b/3 recanalization, were strong predictors of favorable clinical outcome at 90 days (p<0.001 and p<0.0001, respectively). CONCLUSIONS: Our study indicates that endovascular treatment of WUS with stent retrievers and aspiration thrombectomy is safe and effective.

Correlation between cerebral blood volume values and outcomes in endovascular therapy for acute ischemic stroke.

BACKGROUND: Neurointerventionalists do not agree about the optimal imaging protocol when evaluating patients with acute stroke for potential endovascular revascularization. Preintervention cerebrovascular blood volume (CBV) has been shown to predict outcomes in patients undergoing intra-arterial stroke therapies. OBJECTIVE: To determine whether CBV can predict hemorrhagic transformation and clinical outcomes in patients selected for endovascular therapy for acute ischemic middle cerebral artery (MCA) stroke using a CT perfusion (CTP)-based imaging protocol. METHODS: We retrospectively reviewed cases of acute ischemic stroke due to MCA M1 segment occlusion and correlated favorable clinical outcomes (modified Rankin scale (mRS) ≤2) and radiographic outcomes with preintervention CBV values. All patients underwent whole-brain (320-detector-row) CTP imaging, and absolute CBV values of the affected and contralateral MCA territories were obtained separately for the cortical and basal ganglia regions. RESULTS: Relative CBV (rCBV) of the MCA cortical regions was significantly lower in patients with poor clinical outcomes than in those with favorable clinical outcomes (0.87±0.21 vs 1.02±0.09, p=0.0003), and a negative correlation was found between rCBV values and mRS score severity. rCBV of the basal ganglia region was significantly lower in patients with hemorrhagic infarction (p=0.004) and parenchymal hematoma (p=0.04) than in those without hemorrhagic transformation. CONCLUSIONS: We found that cortical CBV loss is predictive of poor clinical outcomes, whereas basal ganglia CBV loss is predictive of hemorrhagic transformation but without translation into poor clinical outcomes. Our study findings support published results of baseline preintervention CBV as a predictor of outcomes in patients undergoing intra-arterial stroke therapies.

Thrombus density predicts successful recanalization with Solitaire stent retriever thrombectomy in acute ischemic stroke.

BACKGROUND: Thrombus characteristics, including Hounsfield unit (HU) value to measure density and thrombus volume and length, can predict successful recanalization following IV thrombolysis with recombinant tissue plasminogen activator. Conflicting and limited data exist regarding the value of assessing thrombus properties in acute stroke cases treated with endovascular IA approaches. METHODS: We retrospectively reviewed cases of anterior circulation acute ischemic stroke in which a Solitaire stent retriever (ev3-Covidien) was the primary treatment device. We measured the following thrombus characteristics: absolute and corrected HU values; thrombus length and volume; clot burden score; and vessel bifurcation involvement. Fisher's exact test and the t test were used to study the association between these clot characteristics and successful recanalization (Thrombolysis in Cerebral Infarction (TICI) score 2b-3). RESULTS: We identified 41 patients with anterior circulation stroke treated with the Solitaire stent retriever as the primary treatment device. Successful recanalization (TICI score 2b-3) was achieved in 59% of cases. Higher absolute and corrected HU values were strongly predictive of successful recanalization (49.9±7.6 vs 43.8±6.6, p=0.01 for absolute HU values and 1.2±0.2 vs 1.0±0.1, p=0.03 for HU ratio in TICI 2b-3 and TICI 0-2a groups, respectively). There was no significant difference between recanalization and non-recanalization groups in the other thrombus characteristics studied. CONCLUSIONS: In acute stroke treated with Solitaire stent retriever thrombectomy, higher thrombus HU values are predictive of successful recanalization. Such information can be used in decision making when estimating recanalization success rate with different endovascular treatment approaches.

Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: a multicenter retrospective analysis of 1122 patients.

BACKGROUND AND PURPOSE: Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy. METHODS: Retrospective analysis of consecutive patients presenting to 13 high volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 h from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PHs), as well as 90 day poor outcome (modified Rankin Scale score ≥3) and mortality. RESULTS: There were a total of 363 ICHs (overall rate 32.3%; HI=267, 24%; PH=96, 8.5%) among the 1122 study patients (mean age 67±15 years; median National Institutes of Health Stroke Scale score 17 (IQR 13-20)). Independent predictors for HI included diabetes mellitus (OR 2.27, 95% CI (1.58 to 3.26), p<0.0001), preprocedure IV tissue plasminogen activator (tPA) (1.43 (1.03 to 2.08), p<0.037), Merci thrombectomy (1.47 (1.02 to 2.12), p<0.032), and longer time to puncture (1.001 (1.00 to 1.002), p<0.026). Patients with atrial fibrillation (1.61 (1.01 to 2.55), p<0.045) had a higher risk of PH while the use of IA tPA (0.57 (0.35 to 0.90), p<0.008) was associated with lower chances of PH. Both the presence of HI (2.23 (1.53 to 3.25), p<0.0001) and PH (6.24 (3.06 to 12.75), p<0.0001) were associated with poor functional outcomes; however, only PH was associated with higher mortality (3.53 (2.19 to 5.68), p<0.0001). CONCLUSIONS: Greater understanding about the predictors and consequences of ICH post endovascular stroke therapy is essential to improve risk assessment, patient selection/clinical outcomes, and early prognostication. Our data suggest that patients with atrial fibrillation are particularly prone to severe ICH and question the 'benign' nature of HI suggested by earlier studies.

Direct access to the middle meningeal artery for embolization of complex dural arteriovenous fistula: a hybrid treatment approach.

Endovascular embolization has become increasingly favored over microsurgical resection for treatment of complex dural arteriovenous fistulas (DAVFs). However, endovascular treatment can be restricted by tortuous transarterial access and a transvenous approach is not always feasible. We present a Borden III DAVF treated by direct access to the middle meningeal artery (MMA) and Onyx embolization performed in a hybrid operating room-angiography suite. A middle-aged patient with pulsatile headaches was found to have left transverse sinus occlusion and DAVF with retrograde cortical venous drainage fed by multiple external carotid artery (ECA) feeders. Endovascular attempts via conventional transvenous and transarterial routes were unsuccessful, and the major MMA feeder was accessed directly after temporal craniotomy was performed under neuronavigation. Onyx embolization was performed; complete occlusion of the fistula was achieved. Three-month follow-up angiography showed no residual filling; the patient remains complication-free. A combined surgical-endovascular technique in a hybrid operating room-angiography suite can be an effective treatment for DAVFs complicated by inaccessible arterial and transvenous approaches.

Primary stenting for acute ischemic stroke using the Enterprise vascular reconstruction device: early results.

OBJECTIVE: Primary stenting for acute ischemic stroke (AIS) using the Wingspan stent delivery system has been reported. Major technical limitations in that study were difficulties in delivering the device and a few cases in which the Enterprise vascular reconstruction device (stent) was used as a bailout procedure. The Enterprise, which has relatively less radial force and more flexibility than other intracranial stents, is an ideal device for revascularization as it is easily delivered through tortuous intracranial vessels. We tested the safety and effectiveness of this stent as the primary revascularization device for AIS in an FDA-approved investigational device exemption prospective cohort study. METHODS: Twenty patients presenting with AIS due to confirmed intracranial large vessel occlusion within 8 h of onset of stroke symptoms were treated with the Enterprise as the primary revascularization device. The primary outcome was recanalization to Thrombolysis In Myocardial Infarction (TIMI) flow of ≥2. Perioperative safety was measured by major complication incidence within 30 days of stent revascularization. A secondary measure of outcome was 30-day modified Rankin Scale (mRS) score. RESULTS: Recanalization to TIMI 2 (n=6) or 3 (n=12) flow was achieved in 18 patients (90% revascularization rate). Three major complications were noted (15%) including one myocardial infarction, one symptomatic intracranial hemorrhage and one ischemic stroke in a distribution other than the qualifying vessel. Good outcome (mRS ≤2) was obtained in 10 patients (50%). CONCLUSIONS: In this prospective study the Enterprise stent was found to be a safe and effective revascularization tool in the setting of AIS.

Carotid artery stenting outcomes: do they correlate with antiplatelet response assays?

OBJECTIVE: Limited data exist regarding the use of antiplatelet response assays during neuroendovascular intervention. We report outcomes after carotid artery stenting (CAS) based on aspirin and P2Y12 assays. METHODS: We retrospectively identified patients who had aspirin and P2Y12 assays at the time of stenting. Aspirin (325 mg) and clopidogrel (75 mg) were started 7-10 days pre-intervention. If not possible, aspirin (650 mg) and clopidogrel (600 mg) loading doses were given pre-intervention. Assays were checked on postoperative day 0/1. Outcomes included neurological ischemic sequela at 30 days, 1 and 2 years, as well as 30 day death/hemorrhage/myocardial infarction. RESULTS: 449 patients were included. Mean P2Y12 reaction unit (PRU) values were higher in patients with an ipsilateral ischemic event (stroke/transient ischemic attack (TIA)) or stroke (alone) at 1 and 2 years than in patients with no events: ischemic event versus no event at 1 year, 252 vs 202 (p=0.008); stroke versus no stroke at 1 year, 252 versus 203(p=0.029); ischemic event versus no event at 2 years, 244 vs 203 (p=0.047); stroke versus no stroke at 2 years, 243 versus 203 (p=0.082). Ischemic event free survival (stroke/TIA, p=0.0268) and overall survival (p=0.0291) post-CAS were longer in patients with PRU ≤198 compared with an initial threshold of PRU ≤237. Mean PRU values were higher in patients who died from all causes at 30 days than in survivors (p=0.031). No correlation was found between lower PRU values and hemorrhage. Aspirin reaction units did not correlate with outcome. CONCLUSIONS: PRU ≤198 may be associated with a lower incidence of ischemic neurological sequela and death post-CAS. Prospective studies are needed to validate the relationship between antiplatelet assays and outcomes post-CAS.

The expanding realm of endovascular neurosurgery: flow diversion for cerebral aneurysm management.

The worldwide prevalence of intracranial aneurysms is estimated to be between 5% and 10%, with some demographic variance. Subarachnoid hemorrhage secondary to ruptured intracranial aneurysm results in devastating neurological outcomes, leaving the majority of victims dead or disabled. Surgical clipping of intracranial aneurysms remained the definitive mode of treatment until Guglielmi detachable coils were introduced in the 1990s. This revolutionary innovation led to the recognition of neurointervention/neuroendovascular surgery as a bona fide option for intracranial aneurysms. Constant evolution of endovascular devices and techniques supported by several prospective randomized trials has catapulted the endovascular treatment of intracranial aneurysms to its current status as the preferred treatment modality for most ruptured and unruptured intracranial aneurysms. We are slowly transitioning from the era of coils to the era of flow diverters. Flow-diversion technology and techniques have revolutionized the treatment of wide-necked, giant, and fusiform aneurysms, where the results of microsurgery or conventional neuroendovascular strategies have traditionally been dismal. Although the Pipeline Embolization Device (ev3-Covidien, Irvine, CA) is the only flow-diversion device approved by the Food and Drug Administration for use in the United States, others are commercially available in Europe and South America, including the Silk (Balt Extrusion, Montmorency, France), Flow-Redirection Endoluminal Device (FRED; MicroVention, Tustin, CA), Surpass (Stryker, Kalamazoo, MI), and p64 (Phenox, Bochum, Germany). Improvements in technology and operator experience and the encouraging results of clinical trials have led to broader acceptance for the use of these devices in cerebral aneurysm management. Continued innovation and refinement of endovascular devices and techniques will inevitably improve technical success rates, reduce procedure-related complications, and broaden the endovascular therapeutic spectrum for varied aneurysm morphology.

Vascular decomposition using weighted approximate convex decomposition.

OBJECTIVE: Stroke treatment often requires analysis of vascular pathology evaluated using computed tomography (CT) angiography. Due to vascular variability and complexity, finding precise relationships between vessel geometries and arterial pathology is difficult. A new convex shape decomposition strategy was developed to understand complex vascular structures and synthesize a weighted approximate convex decomposition (WACD) method for vascular decomposition in computer-aided diagnosis. MATERIALS AND METHODS: The vascular tree is decomposed into optimal number of components (determined by an expert). The decomposition is based on two primary features of vascular structures: (i) the branching factor that allows structural decomposition and (ii) the concavity over the vessel surface seen primarily at the site of an aneurysm. Such surfaces are decomposed into subcomponents. Vascular sections are reconstructed using CT angiograms. Next the dual graph is constructed, and edge weights for the graph are computed from shape indices. Graph vertices are iteratively clustered by a mesh decimation operator, while minimizing a cost function related to concavity. RESULTS: The method was validated by first comparing results with an approximate convex decomposition (ACD) method and next on vessel sections (n = 177) whose number of clusters (ground truth) was predetermined by an expert. In both cases, WACD produced promising results with 84.7 % of the vessel sections correctly clustered and when compared with ACD produced a more effective decomposition. Next, the algorithm was validated in a longitudinal study data of 4 subjects where volumetric and surface area comparisons were made between expert segmented sections and WACD decomposed sections that contained aneurysms. The results showed a mean error rate of 7.8 % for volumetric comparisons and 10.4 % for surface area comparisons. CONCLUSION: Decomposition of the cerebral vasculature from CT angiograms into a geometrically optimal set of convex regions may be useful for computer-assisted diagnosis. A new WACD method capable of decomposing complex vessel structures, including bifurcations and aneurysms, was developed and tested with promising results.

Newtonian viscosity model could overestimate wall shear stress in intracranial aneurysm domes and underestimate rupture risk.

OBJECTIVE: Computational fluid dynamics (CFD) simulations of intracranial aneurysm hemodynamics usually adopt the simplification of the Newtonian blood rheology model. A study was undertaken to examine whether such a model affects the predicted hemodynamics in realistic intracranial aneurysm geometries. METHODS: Pulsatile CFD simulations were carried out using the Newtonian viscosity model and two non-Newtonian models (Casson and Herschel-Bulkley) in three typical internal carotid artery saccular aneurysms (A, sidewall, oblong-shaped with a daughter sac; B, sidewall, quasi-spherical; C, near-spherical bifurcation). For each aneurysm model the surface distributions of shear rate, blood viscosity and wall shear stress (WSS) predicted by the three rheology models were compared. RESULTS: All three rheology models produced similar intra-aneurysmal flow patterns: aneurysm A had a slowly recirculating secondary vortex near the dome whereas aneurysms B and C contained only a large single vortex. All models predicted similar shear rate, blood viscosity and WSS in parent vessels of all aneurysms and in the sacs of B and C. However, large discrepancies in shear rate, viscosity and WSS among predictions by the various rheology models were found in the dome area of A where the flow was relatively stagnant. Here the Newtonian model predicted higher shear rate and WSS values and lower blood viscosity than the two non-Newtonian models. CONCLUSIONS: The Newtonian fluid assumption can underestimate viscosity and overestimate shear rate and WSS in regions of stasis or slowly recirculating secondary vortices, typically found at the dome in elongated or complex-shaped saccular aneurysms as well as in aneurysms following endovascular treatment. Because low shear rates and low WSS in such flow conditions indicate a high propensity for thrombus formation and rupture, CFD based on the Newtonian assumption may underestimate the propensity of these events.

Endovascular treatment of patients with intracranial stenosis with moyamoya-type collaterals.

PURPOSE: The authors report the endovascular treatment of intracranial stenosis in six patients with moyamoya-type collaterals. PATIENTS: All patients previously had experienced a stroke or transient ischemic attack. Lesion locations included a unilateral M1-segment lesion in five patients; and ipsilateral internal carotid artery (ICA)-T, M1 and A1 lesions with contralateral supraclinoid ICA stenosis in one patient. Mean M1 stenosis was 77.3 ± 14.3%. RESULTS: Six patients had balloon angioplasty; in one, a Wingspan stent deployed successfully after angioplasty failed to relieve the stenosis. Mean post-treatment stenosis was 41.0 ± 33.0%. In one patient, vessel rupture occurring during angioplasty caused severe disability. Two patients were asymptomatic for 4 years and 6 months, respectively. One asymptomatic patient had severe restenosis re-treated with intracranial stenting. Two patients became symptomatic and had re-treatment at 1 and 2 months, respectively. CONCLUSION: Endovascular treatment of intracranial stenosis with moyamoya-type collaterals is possible but is associated with high rates of symptomatic restenosis and target-lesion revascularization.

Stent-assisted coiling of paraclinoid aneurysms: risks and effectiveness.

BACKGROUND: Stent assistance for treatment of wide-based aneurysms is becoming rapidly accepted. METHODS: Cases of aneurysms arising in the paraclinoid location of the internal carotid artery treated with intracranial stents and/or bare platinum coils were analyzed retrospectively from our prospectively collected database. We identified 70 aneurysms treated with stent assistance (including one stenting-alone case) and 24 aneurysms treated with coiling alone. Stenting-assisted coiling was achieved either as a one-time treatment or as a two-step maneuver with the stent placed several weeks before coiling, or stent-assisted coiling was used as a second maneuver in aneurysms that recanalized after previous coiling. RESULTS: In aneurysms treated with stent assistance, 60% had ≥95% occlusion at treatment completion, a result comparing favorably with the 54.2% rate of ≥95% occlusion associated with coiling alone. At last follow-up, 60 aneurysms treated with stent assistance had a 66.7% incidence of ≥95% occlusion, with no in-stent stenosis; 75% of patients treated with coiling alone had ≥95% aneurysm occlusion. Thrombus occurred during stent deployment in two patients, one with and one without neurologic sequelae; stent displacement occurred in one patient without neurologic sequelae. At last follow-up, 57 of 62 patients (91.9%) treated with stent-assisted coiling experienced excellent/good outcomes (modified Rankin scale score ≤2). These results compared favorably with those for the coiling-alone group in which 23 of 24 (95.8%) had good outcomes. CONCLUSION: Stent-assisted coiling of paraclinoid aneurysms did not add significantly to morbidity; overall effectiveness was comparable to that of bare coiling of paraclinoid aneurysms. These results require confirmation by a prospective controlled trial.

Salvage Neuroform stent-assisted coiling for recurrent giant aneurysm after waffle-cone treatment.

We report a case of aneurysm progression after waffle-cone treatment. A patient in their seventies presented with headaches. Four years earlier, this individual had undergone waffle-cone treatment of a giant ruptured left ophthalmic aneurysm. Angiography demonstrated aneurysm growth. A second stent was deployed through the initially placed stent to recreate the aneurysm neck and to provide support for stent-assisted coiling. The residual aneurysm was coiled with good outcome.

Stent-assisted basilar reconstruction for a traumatic vertebral dissection with a large basilar artery thrombosis.

An individual in their 30s presented with quadriplegia and coma 7 h after a 30-foot free-fall. Angiography confirmed left vertebral artery dissection causing vertebral artery occlusion (thrombolysis in myocardial infarction (TIMI) 0) and basilar artery thrombosis. Deployment of six self-expanding intracranial stents (right P1 to left V3) resulted in recanalization (TIMI 3). Postoperative MRI demonstrated a large brainstem infarction; the patient was 'locked-in'. In the following 6 months, the patient recovered to ambulation and independence. Aggressive recanalization for symptomatic vertebrobasilar dissection/occlusion may be considered. Despite major diffusion-weighted imaging brainstem lesions, recovery is possible.

Use of the outreach distal access catheter as an intracranial platform facilitates coil embolization of select intracranial aneurysms: technical note.

OBJECTIVE: The Outreach distal access catheter (DAC; Concentric Medical, Mountain View, California, USA) has been designed to assist the Merci device (Concentric Medical) with clot retrieval in the setting of acute stroke. Its application for coil embolization of intracranial aneurysms was investigated. METHODS: Between December 2008 and January 2010, 150 aneurysms were treated with endovascular methods. In 18 cases of small aneurysms and/or increased parent vessel tortuosity, the DAC was used for additional support. Merits and complications related to the use of this catheter are reviewed. RESULTS: The mean aneurysm size was 7.1 mm (range 3.5-25). In each case, the DAC was used as an intracranial platform catheter in close proximity to the target aneurysm. This catheter (outer diameter 3.9 or 4.3 French) increased the stability and reduced the redundancy of the microcatheter. As a result, handling and control of the microcatheter were improved. In three cases, the coiling procedure could not be completed because of difficulties not related to the DAC. Aneurysms in the remaining patients were treated successfully with complete (n=12) or near complete (n=3) angiographic occlusion. CONCLUSION: For smaller or distal intracranial aneurysms with difficult access, use of the DAC as an additional platform in close proximity to the target aneurysm subjectively enhanced microcatheter control and safety.

Safety and feasibility of intraarterial eptifibatide as a revascularization tool in acute ischemic stroke.

OBJECT: Experience with the use of platelet glycoprotein (GP) IIb-IIIa inhibitor eptifibatide in patients with ischemic stroke is limited. The authors report the off-label use of intraarterial eptifibatide during endovascular ischemic stroke revascularization procedures for reocclusion after documented recanalization or formed fresh thrombi in distal vessels that were inaccessible to endovascular devices. METHODS: Patients who received intraarterial eptifibatide were identified from a prospectively collected database of patients in whom endovascular revascularization for acute ischemic stroke was attempted between 2005 and 2008. Data were analyzed retrospectively. The intraarterial eptifibatide dose was a single-bolus dose of 180 µg/kg body weight. Primary outcome measures were angiographic recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3), symptomatic intracranial hemorrhage rate, overall mortality rate, and favorable 3-month modified Rankin Scale score (≤ 2). RESULTS: The study included 35 patients (mean age 62 years, range 18-85 years). The median presenting National Institutes of Health Stroke Scale score was 13. Two patients received intravenous tissue plasminogen activator before endovascular therapy. The median time from symptom onset to therapy initiation was 230 minutes (range 90-1370 minutes). Twelve patients (34%) received intraarterial tissue plasminogen activator without mechanical measures. Mechanical revascularization measures used were Merci retriever in 19 (54%), Penumbra device in 1 (3%), balloon angioplasty in 15 (43%), and stent placement in 22 (63%) patients. The mean dose of intraarterial eptifibatide was 11.6 mg (range 5-16.6 mg). Partial-to-complete recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3) was achieved in 27 patients (77%). Postprocedure intracranial hemorrhage occurred in 13 patients (37%), causing symptoms in 5 (14%). In the 5 symptomatic intracranial hemorrhage cases, all patients but one presented more than 8 hours after symptom onset and all received intraarterial recombinant tissue plasminogen activator. The median discharge National Institutes of Health Stroke Scale score was 7 (range 0-17). At 3 months postprocedure, 21 patients (60%) had a modified Rankin Scale score ≤ 2, and 8 patients (23%) had died. CONCLUSIONS: Adjunctive intraarterial eptifibatide is a feasible option for salvage of reocclusion and thrombolysis of distal inaccessible thrombi during endovascular stroke revascularization. Its safety and efficacy need to be studied further in larger, multicenter, controlled studies.

Retrograde trans-posterior communicating artery snare-assisted rescue of lost access to a foreshortened pipeline embolization device: complication management.

BACKGROUND AND IMPORTANCE: The Pipeline embolization device (PED; Covidien Vascular Therapies, Mansfield, Massachusetts) is a promising, yet experimental, vascular reconstruction device for the treatment of complex intracranial aneurysms. We present a PED-related complication and describe a salvage strategy. CLINICAL PRESENTATION: A 64-year-old woman underwent PED-assisted parent vessel reconstruction for her giant cavernous internal carotid artery (ICA) aneurysm. During placement of the first PED, the proximal part of the PED foreshortened and was displaced into the aneurysm sac. Multiple subsequent attempts to recatheterize the PED failed, and, ultimately, distal access through and beyond the PED was lost. Therefore, completion of the Pipeline construct by stacking PEDs for definitive treatment was prevented. Retrograde access of the PED was gained from the distal ICA through a microwire that was advanced from the basilar artery through the posterior communicating artery. The microwire from the distal ICA was grasped with a snare from the proximal ICA and pulled down to the cervical ICA. The opened snare around the microwire was used as a lasso to advance a microcatheter from the cervical ICA through the PED to regain distal access. Five more PEDs were used to achieve complete parent vessel reconstruction and aneurysm obliteration. CONCLUSION: Maintaining distal access is critical until the entire parent vessel is reconstructed, especially when multiple PEDs are required. The salvage technique described may help regain distal access if it is lost during the procedure.