Critical care guidelines on the endovascular management of cerebral vasospasm.

Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. A total of 49 articles were identified, addressing endovascular treatment timing, intra-arterial treatments, and balloon angioplasty. Most of the available studies investigated intra-arterial papaverine or balloon angioplasty. Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.

Primary intracranial stenting in acute ischemic stroke.

Acute intracranial stroke is a major source of morbidity and mortality in the United States. Recent studies have shown improved clinical outcomes for patients who achieve timely arterial recanalization. Multimodal therapies have evolved to meet this end point and include intravenous and/or intra-arterial thrombolysis and mechanical thrombolysis. Modifications to existing balloon-mounted stents commonly used in cardiology have yielded more easily navigable and safer self-expanding intracranial stents that provide rapid arterial recanalization. We review the evolution of acute stroke therapy over the past few decades and the recent results of mechanical thrombolysis, focusing on intracranial stenting in the setting of acute stroke.

Direct thrombolysis for cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) is an increasingly diagnosed disease with a wide range of symptoms, ranging from a mild headache to cerebral herniation. A potentially devastating syndrome, CVST has been associated with a mortality rate of 6-10%. In prospective studies, the overall rate of death and dependency from CVST ranges from 8.8 to 44.4%. Systemic anticoagulation remains the first-line treatment. However, a percentage of patients deteriorate despite medical therapy. These cases have resulted in the development of thrombolysis or endovascular treatment for CVST. Initial reports of the use of endovascular treatment of CVST have been promising. However, enthusiasm for the use of endovascular thrombolysis and thrombectomy should be tempered by an understanding of possible risks such as intracerebral hemorrhage and/or vessel dissection. The authors review the literature regarding endovascular treatment of CVST with a description of the chemical and mechanical thrombolytic techniques.

Clinical course of nontraumatic, nonaneurysmal subarachnoid hemorrhage: a single-institution experience.

OBJECT: Angiogram-negative subarachnoid hemorrhage (SAH) accounts for 15% of nontraumatic SAH and has been reported with low morbidity and mortality rates. We report on a large series of patients with angiogram-negative SAH who experienced an atypical nonbenign clinical course. METHODS: Between December 2001 and November 2006, 95 patients with spontaneous nonaneurysmal SAH and negative initial angiographic evaluation were treated at the University of Florida. The authors retrospectively reviewed the patients' medical records and radiological images to determine associated morbidity and mortality. RESULTS: Aneurysms were found in 6 of the 95 patients on follow-up imaging after an initial negative angiogram (6.3% false negative rate); these patients were excluded leaving 89 patients as the study group. Hydrocephalus necessitating temporary CSF diversion developed in 22 of these patients (25%); 12 (13%) ultimately required permanent CSF diversion. Clinically significant vasospasm developed in 4 patients (4%), and 2 (2%) had cerebral infarctions. Three patients (3%) died. CONCLUSIONS: The authors' experience with a large series of angiogram-negative SAH patients who had an atypical nonbenign clinical course associated with hydrocephalus, vasospasm, stroke, and mortality differs significantly from previously published case series of angiogram-negative SAH.

Alpha-II spectrin breakdown products in aneurysmal subarachnoid hemorrhage: a novel biomarker of proteolytic injury.

OBJECT: Aneurysmal subarachnoid hemorrhage (ASAH) is a serious event with grave consequences. Delayed ischemic neurological deficits caused by cerebral arterial vasospasm contribute significantly to death and disability. Biomarkers may reflect brain injury and provide an early warning of impending neurological decline and stroke from ASAH-induced vasospasm. Alpha-II spectrin is a cytoskeletal protein whose breakdown products are candidate surrogate markers of injury magnitude, treatment efficacy, and outcome. In addition, all spectrin breakdown products (SBDPs) can provide information on the proteolytic mechanisms of injury. METHODS: Twenty patients who received a diagnosis of Fisher Grade 3 ASAH were enrolled in this study to examine the clinical utility of SBDPs in the detection of cerebral vasospasm in patients with ASAH. All patients underwent placement of a ventriculostomy for continual cerebrospinal fluid drainage within 72 hours of ASAH onset. Cerebrospinal fluid samples were collected every 6 hours and analyzed using Western Blotting for SBDPs. Onset of vasospasm was defined as an acute onset of a focal neurological deficit or a change in Glasgow Coma Scale score of two or more points. All suspected cases of vasospasm were confirmed on imaging studies. RESULTS: Both calpain- and caspase-mediated SBDP levels are significantly increased in patients suffering ASAH. The concentration of SBDPs was found to increase significantly over baseline level up to 12 hours before the onset of cerebral arterial vasospasm. CONCLUSIONS: Differential expression of SBDPs suggests oncotic necrotic proteolysis may be predominant in acute brain injury after ASAH and cerebral arterial vasospasm.

Intraoperative dynamic angiography to detect resolution of Bow Hunter's syndrome: Technical case report.

BACKGROUND: Bow Hunter's syndrome is a rare form of vertebrobasilar insufficiency that may be successfully treated by surgical intervention. Use of intraoperative dynamic transcranial Doppler ultrasound for surgical treatment of vertebrobasilar insufficiency has been described in literature. However, this technique was inconsistent and unreliable in some patients. We present a case of a patient with Bow Hunter's syndrome treated surgically and emphasize the valuable addition of intraoperative dynamic angiography to determine resolution of vertebral artery compromise. CASE DESCRIPTION: The patient was a 58-year-old man with complaints of dizziness, vertigo, and near-syncopal episodes that occurred when he rotated his head to the left. Imaging revealed compromise of the dominant left vertebral artery with leftward head rotation. An anterior cervical approach with decompression of the left subaxial vertebral artery was performed. Significant osteophyte formation was observed. Removal of bone and decompression of the vertebral artery was performed. Intraoperative dynamic angiography confirmed resolution of vertebral artery compression and minimized the amount of decompression. No further intervention was required. CONCLUSION: Intraoperative dynamic angiography is a definitive test to determine hemodynamic resolution of Bow Hunter's syndrome. It offers real-time feedback of vertebral artery decompression, potentially minimizes the amount of decompression, and can be performed safely.

The use of abciximab in the treatment of acute cerebral thromboembolic events during neuroendovascular procedures.

BACKGROUND: Recently, a great interest has emerged regarding the use of abciximab for treatment of stroke. Thromboembolic events that occur during neuroendovascular procedures represent a unique subset of stroke patients because definitive angiographic diagnosis and treatment can be performed immediately. The existing literature on this situation suggests excellent results; however, most publications are case reports, and the largest series is 13 cases. We report our experience using abciximab in the treatment of acute thromboembolic events that occur during neuroendovascular procedures. METHODS: We reviewed the last 1373 consecutive patients who underwent neuroendovascular procedures at the University of Florida from our prospectively maintained clinical database. Of these patients, 29 (2.11%) endovascular cases were complicated by acute cerebral thromboembolic events that were treated with abciximab. Abciximab was administered in less than 1 hour after the onset of the occlusion in every patient. The Thrombolysis In Myocardial Infarction (TIMI) scale was used to measure immediate angiographic outcome, and the Modified Rankin Scale (MRS) was used to measure clinical outcome at the time of follow-up. Independent outcome was defined as an MRS of 3 or less at follow-up. RESULTS: Angiographic improvement in the TIMI grade was achieved in 29 (81%) of 36 arteries. Three intracerebral hemorrhages occurred with abciximab when administered with concurrent mechanical clot disruption; in two of these hemorrhages, recombinant tissue plasminogen activator (r-tPA) was also administered. The mean follow-up time for the living cohort was 7.54 months. Twenty-four (83%) patients were independent at follow-up, 3 (10%) were dependent at follow-up, and 2 (7%) died. CONCLUSION: Abciximab appears to be safe and effective in the treatment of acute cerebral thromboembolic complications during neuroendovascular procedures.

Stromal cell-derived factor-1 promoted angiogenesis and inflammatory cell infiltration in aneurysm walls.

OBJECT: A small percentage of cerebral aneurysms rupture, but when they do, the effects are devastating. Current management of unruptured aneurysms consists of surgery, endovascular treatment, or watchful waiting. If the biology of how aneurysms grow and rupture were better known, a novel drug could be developed to prevent unruptured aneurysms from rupturing. Ruptured cerebral aneurysms are characterized by inflammation-mediated wall remodeling. The authors studied the role of stromal cell-derived factor-1 (SDF-1) in inflammation-mediated wall remodeling in cerebral aneurysms. METHODS: Human aneurysms, murine carotid artery aneurysms, and murine intracranial aneurysms were studied using immunohistochemistry. Flow cytometry analysis was performed on blood from mice developing carotid or intracranial aneurysms. The effect of SDF-1 on endothelial cells and macrophages was studied by chemotaxis cell migration assay and capillary tube formation assay. Anti-SDF-1 blocking antibody was given to mice and compared with control (vehicle)-administered mice for its effects on the walls of carotid aneurysms and the development of intracranial aneurysms. RESULTS: Human aneurysms, murine carotid aneurysms, and murine intracranial aneurysms all expressed SDF-1, and mice with developing carotid or intracranial aneurysms had increased progenitor cells expressing CXCR4, the receptor for SDF-1 (p < 0.01 and p < 0.001, respectively). Human aneurysms and murine carotid aneurysms had endothelial cells, macrophages, and capillaries in the walls of the aneurysms, and the presence of capillaries in the walls of human aneurysms was associated with the presence of macrophages (p = 0.01). Stromal cell-derived factor-1 promoted endothelial cell and macrophage migration (p < 0.01 for each), and promoted capillary tube formation (p < 0.001). When mice were given anti-SDF-1 blocking antibody, there was a significant reduction in endothelial cells (p < 0.05), capillaries (p < 0.05), and cell proliferation (p < 0.05) in the aneurysm wall. Mice given anti-SDF-1 blocking antibody developed significantly fewer intracranial aneurysms (33% vs 89% in mice given control immunoglobulin G, respectively; p < 0.05). CONCLUSIONS: These data suggest SDF-1 is associated with angiogenesis and inflammatory cell migration and proliferation in the walls of aneurysms, and may have a role in the development of intracranial aneurysms.

The stent anchor technique for distal access through a large or giant aneurysm.

Large and giant aneurysms pose significant challenges to the endovascular techniques of coil embolization or parent vessel reconstruction. Many large aneurysms are wide-necked with bulbous domes and frequently require stent-assisted coiling or flow diversion to reconstruct and preserve flow through the parent artery. Often the wire must be looped in the dome before catheterization of the exiting portion of the parent vessel is possible. In addition, it can be challenging to obtain stable distal purchase of the microcatheter that will allow the loop to be withdrawn from the aneurysm without the entire microcatheter unwinding, resulting in herniation into the aneurysm or proximal vessels. The stent anchor technique, a novel method of obtaining distal purchase that allows straightening of the catheter loop within a large aneurysm for the purposes of stenting for vessel reconstruction across large or giant aneurysms, is presented. This technique may facilitate the use of new stent technologies in the treatment of large aneurysms that have traditionally been exceedingly difficult to treat via an endovascular approach.

Flow failure from intracranial atherosclerotic disease: a rationale for endovascular intervention in a population with recurrent symptoms despite maximal medical therapy.

The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial, the first randomized trial to compare best medical therapies with angioplasty and stenting, was halted prematurely owing to a 30-day stroke rate of 14.7% in the angioplasty and stenting arm compared with 5.8% in the medical management arm. These results have led to a paradigm shift away from interventional therapies and back to dual antiplatelet therapy and aggressive medical therapies only for these patients. However, there appears to be a subset of patients with intracranial atherosclerotic disease (ICAD) who are different from the general SAMMPRIS cohort and are defined by flow failure from severe intracranial arterial stenosis resulting in recurrent ischemic symptoms despite maximal medical therapy. Offering the option of endovascular revascularization seems appropriate in this patient population, given their recurrent ischemic events regardless of aggressive medical therapies. This paper provides a rationale for reconsidering the role of interventional therapies in patients with critical intracranial stenosis and presents four patients with flow failure from ICAD and persistent symptoms of ischemia, regardless of dual antiplatelet and adjuvant medical therapies, who subsequently improved with angioplasty. Consideration of alternative patient populations and treatment paradigms seems to carry particular relevance now as the endovascular treatment of intracranial atheromatous disease is currently receiving intense scrutiny by those medical specialties involved in the care of stroke patients, as well as the public at large.

Vertebral brown tumors causing neurologic compromise.

OBJECTIVE: Brown tumors are nonneoplastic lesions that occur only in the setting of hyperparathyroidism. Although vertebral brown tumors are relatively rare pathologic entities, their incidence seems to be on the rise, as evidenced by multiple case reports published during the past four decades. An extensive review of these lesions is lacking in the literature. We present a case of paraparesis secondary to vertebral brown tumor followed by a detailed review of the literature. METHODS: We performed a review of the literature to locate all reported cases to date of vertebral brown tumors resulting in neurologic sequelae. In addition, we present the case of a 33-year-old female with end-stage renal disease and previous subtotal parathyroidectomy who presented with acute-onset paraparesis from an expansile L1 brown tumor and was treated successfully by laminectomy and bracing. RESULTS: Thirty cases of vertebral brown tumor resulting in neurologic deficit were located in our literature search. Most occurred in women (63%), those aged 40 to 49 years (27%), and in the thoracic spine (57%). Lesions occurred roughly equally in primary (47%) and secondary (53%) hyperparathyroidism. Most patients demonstrated either symptomatic or radiographic improvement after neurosurgical intervention and/or subtotal or total parathyroidectomy. CONCLUSION: In patients presenting with a lytic vertebral lesion and known hyperparathyroidism or end-stage renal disease, brown tumor should be considered in the differential diagnosis. In select cases with minimal neurologic symptoms, parathyroidectomy may be warranted prior to neurosurgical intervention.

Concomitant intracranial pressure monitoring during venous sinus stenting for intracranial hypertension secondary to venous sinus stenosis.

BACKGROUND: There is a growing body of literature supporting venous sinus stenosis as a causative etiology for many patients diagnosed with idiopathic intracranial hypertension. Recent series have documented improvement in the pre- and post-stenosis venous pressure gradient as well as clinical symptoms after stenting. Concomitant real time intracranial pressure (ICP) monitoring has not been previously described during venous sinus stenting. CASE REPORT: A woman in her twenties presented with rapidly progressive visual loss and cranial neuropathies with an MRI revealing high grade right transverse sinus stenosis. Lumbar puncture demonstrated an opening pressure >55 cm H2O. Her vision and cranial neuropathies continued to worsen despite ventriculoperitoneal shunting. A parenchymal ICP monitoring wire was placed, revealing ICP persistently >70 cm H2O. She underwent venography and a pre- to post-stenosis pressure gradient of 55 mm Hg was measured. The patient underwent sinus stenting resulting in a near immediate reduction in her ICP from 70 to 20 cm H2O within 30 s after deployment. Her ICP completely normalized within 24 h of stenting. CONCLUSIONS: A case is presented of severe intracranial hypertension with rapidly progressive neurologic decline despite CSF diversion secondary to venous sinus stenosis that resolved following venous sinus stenting. This is the first report of real time ICP monitoring during venous sinus stenting.

Enhanced staff communication and reduced near-miss errors with a neurointerventional procedural checklist.

INTRODUCTION: Over the past several decades, checklists have emerged in a variety of different patient care settings to help reduce medical errors and ensure patient safety. To date, there have been no published accounts demonstrating the effectiveness of checklists designed specifically for the unique demands of neurointerventional procedures. METHODS: A three-part, 20-item checklist was developed specific to neurointerventional procedures using the WHO surgical checklist as a template. Staff members (nurses, radiation technologists and physicians) were surveyed regarding near-miss adverse events and the quality of communication immediately following each neurointerventional procedure for 4 weeks prior to implementation of the checklist and again for 4 weeks after using the checklist. Staff members were asked to complete final surveys at the end of the study period. RESULTS: 71 procedures were performed during the 4 weeks prior to checklist implementation and 60 procedures were performed during the 4 weeks after institution of the checklist. Post-checklist surveys indicated significantly improved communication compared with pre-checklist surveys (χ(2) 29.4, p<0.001). The number of adverse events was lower after checklist implementation for eight of the nine adverse event types (not individually significant), but the total number of adverse events was significantly lower after checklist implementation (χ(2) 11.4, p=0.001). Final staff surveys were uniformly positive with 95% of individuals indicating that the checklist should be continued in the department. CONCLUSIONS: Use of a neurointerventional procedural checklist resulted in statistically significant improvements in team communication and a significant reduction in total adverse events, with uniformly positive staff feedback.

Occurrence of angiographic femoral artery complications after vascular closure with Mynx and AngioSeal.

INTRODUCTION: There have been recent reports of high vascular complication rates after the use of the Mynx vascular closure device (VCD). At our institution, vascular complications due to these devices have rarely been encountered. A study was undertaken to retrospectively compare angiographic abnormalities seen after femoral artery closure by both the Mynx and AngioSeal VCDs to provide further insight into the risks associated with VCDs. METHODS: All adult patients who underwent deployment of either a Mynx or AngioSeal VCD and subsequently underwent repeat angiography within the next 30 days between 1 July 2010 and 1 April 2011 were reviewed. Two independent blinded radiologists compared blinded pre-procedure and follow-up femoral angiograms for the presence of pseudoaneurysm or other vascular abnormality. Hospital records were reviewed for major or minor complications of the groin site or femoral artery. RESULTS: Thirty patients (31 angiograms) underwent vascular closure with a Mynx and 57 patients (69 angiograms) received an AngioSeal. The average time elapse until repeat femoral angiography was 6.2 days (range 1-21, median 5.5 days) in the Mynx group and 6.3 days (range 0-30, median 5 days) in the AngioSeal group. Two pseudoaneurysms and one minor stenosis were identified in the AngioSeal group. No angiographic abnormalities were seen in the Mynx group. No intraluminal filling defects were demonstrated on any of the follow-up femoral angiograms. One patient who received an AngioSeal developed a delayed minor groin site hematoma that did not require surgical intervention. CONCLUSIONS: Angiographic complications were seen in only 3% of patients after closure with Mynx or AngioSeal VCDs. There were no clinically significant groin site or vascular complications. These data suggest that both VCDs are safe for use after angiography with a low rate of femoral artery complications.

Surgical outcomes for moyamoya angiopathy at barrow neurological institute with comparison of adult indirect encephaloduroarteriosynangiosis bypass, adult direct superficial temporal artery-to-middle cerebral artery bypass, and pediatric bypass: 154 revascularization surgeries in 140 affected hemispheres.

BACKGROUND: Untreated, moyamoya angiopathy is a progressive vaso-occlusive process that can lead to ischemic or hemorrhagic stroke. OBJECTIVE: To review 1 institution's surgical experience with both direct and indirect bypass (encephaloduroarteriosynangiosis) in adult and pediatric groups. METHODS: A retrospective review was conducted of a consecutive series of patients treated for moyamoya angiopathy between 1995 and 2009. RESULTS: Thirty-nine adult patients underwent indirect bypass as their initial therapy; 29 adult patients underwent direct bypass. Twenty-four pediatric patients included 20 indirect bypasses and 4 direct bypasses. Overall, 140 hemispheres were treated; 48 patients received revascularization of both hemispheres. There were 14 additional revascularization procedures (10% per hemisphere) performed over a site of continued hypoperfusion postoperatively. Fourteen postoperative ischemic strokes occurred during the entire follow-up (10% per hemisphere), and the Kaplan-Meier analysis was not significantly different between groups (P = .59). Four grafts (9.09%) had failed at radiographic follow-up of the 44 direct bypasses performed. Before the initial surgery, the modified Rankin Scale score was 1.58 ± 0.93, 1.48 ± 0.74, and 1.8 ± 1.1 in the pediatric, adult direct, and adult indirect groups (P = .39). At last follow-up, it was 1.29 ± 1.31, 1.09 ± 0.90, and 1.94 ± 1.51 (P = .04) in the pediatric, adult direct, and adult indirect groups. CONCLUSION: This series demonstrates that both direct and indirect bypasses can be equally effective in preventing stroke. However, in adult patients, direct bypass patients had significantly greater improvement in symptoms, as seen in modified Rankin Scale scores. Pediatric patients, despite undergoing predominantly indirect bypasses, fared roughly the same as the adults in the direct bypass group.

Surgical management of giant posterior communicating artery aneurysms.

BACKGROUND: Giant posterior communicating artery (PCoA) aneurysms (> 25 mm) are rare lesions associated with a poor prognosis and high rates of morbidity and mortality. OBJECTIVE: To review the clinical results of giant PCoA aneurysms surgically treated at our institution, focusing on operative nuances. METHODS: All cases of giant PCoA aneurysms treated surgically at our institution were identified from a prospectively maintained patient database. Patient demographic factors, medical comorbidities, rupture status, neurological presentation, clinical outcomes, and surgical records were critically reviewed. RESULTS: From 1989 to 2010, 11 patients (10 women) underwent surgical clipping of giant PCoA aneurysms. Presenting signs and symptoms included cranial nerve palsies, diminished mental status, headache, visual changes, and seizures. Five aneurysms were ruptured on admission. All aneurysms were clipped primarily except 1, which was treated by parent artery sacrifice and extracranial-to-intracranial bypass after intraoperative aneurysm rupture. Perioperative morbidity and mortality rates were 36% (4 of 11) and 18.3% (2 of 11), respectively. Excellent or good clinical outcomes, defined as modified Rankin Scale scores ≤ 2, were achieved in 86% (5 of 6) of patients available for long-term clinical follow-up (mean, 12.5 ± 13.6 months). CONCLUSION: Giant PCoA aneurysms are rare vascular lesions that may present with a variety of neurological signs and symptoms. These lesions can be successfully managed surgically with satisfactory morbidity and mortality rates. To the best of our knowledge, this is the largest surgical series of giant PCoA aneurysms published to date.

Direct radial artery access with the 070 neuron guide catheter for aneurysm coiling: a novel application of the neuron catheter for cerebral interventions.

BACKGROUND AND IMPORTANCE: Most neuroendovascular interventions rely on a transfemoral approach to the intracranial circulation; however, this is sometimes not possible because of complex aortic arch anatomy or femoral arterial disease. Transradial arteriography and intervention are well established in interventional cardiology, and there have been some reports of successful neurointervention using this technique. The incidence of radial artery occlusion or other access site complications after transradial access is directly related to the outer diameter of the sheath used to access the artery. We describe a novel approach to neuroendovascular intervention using a 070 Neuron guide catheter to directly access the radial artery for complex cerebrovascular intervention. CLINICAL PRESENTATION: We describe a technique to directly access the radial artery with a 070 Neuron catheter, without the need for a large 6-French sheath, for cerebrovascular interventions. Two successful cases are described in which this technique was used. Case 1 describes the successful Y-stent placement for coiling of a basilar tip aneurysm, and case 2 describes coiling of a ruptured posterior inferior cerebellar artery aneurysm. CONCLUSION: The 070 Neuron catheter can be used in a direct access transradial approach to the cerebrovascular circulation for complex interventions without a radial sheath, thereby maximizing guide catheter diameter and minimizing the radial arteriotomy size.

Direct thrombectomy using the Penumbra thromboaspiration catheter for the treatment of cerebral venous sinus thrombosis.

OBJECTIVE: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke. A 21 year-old female presented to our institution in a rapidly deteriorating neurological state following failed systemic heparin therapy for treatment of superior sagittal sinus (SSS) thrombosis. METHODS: The patient underwent emergent mechanical thrombectomy of the thrombosed SSS using the 0.054-inch Penumbra catheter. No adjuvant direct pharmacologic and/or mechanical thrombectomy was performed. RESULTS: Successful venous recanalization was achieved using the Penumbra system. The patient improved symptomatically following the intervention, and she made a complete neurological recovery within 30 days. At 6-month follow-up, the patient had returned to work and school and remained neurologically intact. A repeat MRV showed complete sinus recanalization. CONCLUSION: Direct mechanical thrombectomy using the Penumbra system provided rapid sinus recanalization for the treatment of symptomatic cerebral venous sinus thrombosis. This device is a valuable addition to the neurointerventional armamentarium.

Delayed intraparenchymal hemorrhage following pipeline embolization device treatment for a giant recanalized ophthalmic aneurysm.

The pipeline embolization device has demonstrated clinical success in the management of complex intracranial aneurysms arising along the anterior intracranial circulation with a relatively low complication profile. A case report is presented which describes a novel complication of delayed intraparenchymal hemorrhage following deployment of a pipeline embolization device for the treatment of a previously ruptured partially thrombosed ophthalmic segment aneurysm.

Microsurgical management of glomus spinal arteriovenous malformations: pial resection technique: Clinical article.

OBJECT: Intramedullary, or glomus, spinal arteriovenous malformations (AVMs) are rare vascular lesions amenable to resection with or without adjuvant embolization. The authors retrospectively reviewed the senior author's (R.F.S.'s) surgical series of intramedullary spinal AVMs to evaluate clinical and radiographic outcomes. METHODS: Detailed chart and radiographic reviews were performed for all patients with intramedullary spinal AVMs who underwent surgical treatment between 1994 and 2011. Presenting and follow-up neurological examination results were obtained and graded using the modified Rankin Scale (mRS) and McCormick Scale. Surgical technique, outcomes, complications, and long-term angiographic studies were reviewed. RESULTS: During the study period, 20 patients (10 males and 10 females) underwent resection of glomus spinal AVMs. The mean age at presentation was 30 ± 17 years (range 7-62 years). The location of the AVMs was as follows: cervical spine (n = 10), thoracic spine (n = 9), and cervicothoracic junction (n = 1). The most common presenting signs and symptoms included paresis or paralysis (65%), paresthesias (40%), and myelopathy (40%). Perioperative embolization was performed in the majority (60%) of patients. Pial AVM resection was performed in 17 cases (85%). Angiographically verified AVM obliteration was achieved in 15 patients (75%). At a mean follow-up duration of 45.4 ± 52.4 months (range 2-176 months), 14 patients (70%) remained functionally independent (mRS and McCormick Scale scores ≤ 2). One perioperative complication occurred, yielding a surgical morbidity rate of 5%. Three symptomatic spinal cord tetherings occurred at a mean of 5.7 years after AVM resection. No neurological decline was observed after endovascular and surgical interventions. No deaths occurred. Long-term angiographic follow-up data were available for 9 patients (40%) at a mean of 67.6 ± 60.3 months (range 5-176 months) following AVM resection. Durable AVM obliteration was documented in 5 (83%) of 6 patients. CONCLUSIONS: Intramedullary AVMs may be safely resected with satisfactory clinical and angiographic results. The pial resection technique, which provides subtotal AVM nidus resection, effectively devascularized these lesions, as confirmed on postoperative angiography, without violating the spinal cord parenchyma, thereby potentially reducing iatrogenic injury.