A rare dissecting anterior inferior cerebellar artery aneurysm treated with flow diversion using a silk vista baby device.

BACKGROUND: Dissecting intracranial pseudoaneurysms represent a challenge for treatment both endovascularly and surgically. METHODS: We review the treatment course of a ruptured anterior inferior cerebellar artery (AICA) dissecting pseudoaneurysm in a 50-year-old patient and review the history of dissecting aneurysms and AICA aneurysms treatment. RESULTS: An aneurysm cure was achieved using flow diversion in the AICA. The recent introduction of flow diversion devices that can be deployed through 0.017" microcatheters represents a new avenue for treatment of aneurysms. CONCLUSION: To the best of our knowledge this is the first published case of flow diversion in the(?) AICA to treat a dissecting aneurysm. The introduction of Silk Vista Baby and similar future devices is likely to widen the scope of aneurysm treatment utilizing flow diversion in distal distribution with small parent arteries.

Surveillance imaging after intracranial stent implantation: non-invasive imaging compared with digital subtraction angiography.

BACKGROUND: Digital subtraction angiography (DSA) is the gold standard imaging for detection of in-stent restenosis (ISR) but there is limited literature on optimal non-invasive surveillance imaging. In this study, the ability of CT angiography (CTA) and MR angiography (MRA) compared with DSA in recognizing ISR was assessed. METHODS: A single center database of patients treated with stent implantation for ICAD was accessed. All patients who underwent follow-up imaging with DSA paired with either MRA or CTA within 30 days were included. Two angiography readers and two non-invasive imaging readers measured restenosis with a submillimeter digital caliper. ISR was categorized as: none/minimal, mild (<50%), moderate (≥50-70%) or severe (≥70%). Analysis was performed with weighted κ statistics. RESULTS: 17 cases of individual stents that underwent surveillance imaging with paired DSA and CTA and five stents with paired DSA and MRA were identified. Of those undergoing DSA and CTA, inter-reader agreement produced κ=0.68 (95% CI 0.40 to 0.95) for DSA and κ=0.75 (95% CI 0.55 to 0.95) for CTA. Agreement across CTA and DSA was κ=0.36 (95% CI 0.26 to 0.52). Of those undergoing DSA and MRA, inter-reader agreement produced κ=0.71 (95% CI 0.27 to 1.00) for DSA and κ=1.00 (95% CI 1.00 to 1.00) for MRA. Agreement across MRA and DSA was κ=0.34 (95% CI 0.18 to 0.51). CONCLUSIONS: Good inter-reader agreement exists within DSA, CTA and MRA. However, when comparing non-invasive imaging (CTA and MRA) with DSA, only fair agreement exists. These data suggest that CTA and MRA are not comparable to DSA for evaluation of ISR.

Complications of endovascular therapy for acute ischemic stroke and proposed management approach.

Over the past decade, endovascular therapy has emerged as a promising therapeutic approach for select patients with acute ischemic stroke. However, the morbidity, mortality, and complication rates in intra-arterial recanalization trials are higher than in the National Institute of Neurological Disorders and Stroke trial of IV tissue plasminogen activator. This review discusses common complications associated with endovascular therapy for acute ischemic stroke, avoidance of complications, and management of some of the common complications.

Developing practice recommendations for endovascular revascularization for acute ischemic stroke.

Guidelines have been established for the management of acute ischemic stroke; however, specific recommendations for endovascular revascularization therapy are lacking. Burgeoning investigation of endovascular revascularization therapies for acute ischemic stroke, rapid device development, and a diverse training background of the providers performing the procedures underscore the need for practice recommendations. This review provides a concise summary of the Society of Vascular and Interventional Neurology endovascular acute ischemic stroke roundtable meeting. This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns. It therefore provides an outline for the future development of multisociety guidelines and recommendations to improve patient selection, procedural management, and organizational strategies for revascularization therapies in acute ischemic stroke.

Venous sinus pulsatility and the potential role of dural incompetence in idiopathic intracranial hypertension.

BACKGROUND: Idiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing; however, a complete understanding of the hydrodynamic dysequilibrium is lacking. OBJECTIVE: To review and characterize catheter manometry findings including pulsatility changes within the venous sinuses in IIH. METHODS: Cases of venous sinus stent implantation for IIH were retrospectively reviewed. RESULTS: Three cases of venous sinus stent implantation for treatment of IIH are reported. All cases demonstrated severe narrowing (>70%) within the transverse sinus and a high pressure gradient across the lesion (>30 mm Hg). Stent implantation resulted in pulsatility attenuation, correction of pressure gradient, and improvement of flow. CONCLUSION: We report the finding of high venous sinus pulsatility attenuation after stent implantation for dural sinus narrowing and propose the hypothesis that this finding is a marker of advanced dural sinus incompetence. This characteristic may be useful in identifying patients who would benefit from endovascular stent remodeling.

Pericallosal artery aneurysm treatment using Y-configuration stent-assisted coil embolization: a report of four cases.

BACKGROUND: Pericallosal artery aneurysms at the bifurcation represent a special endovascular technical challenge given their distal location, commonly wide-neck morphology, small parent vessel diameter and potentially high recurrence rate after coiling given the bifurcation location. Y-configuration stent-assisted coil embolization techniques have been reported for the treatment of wide-neck aneurysms located at other vascular bifurcations and only rarely with A2 bifurcation aneurysms. METHODS: A neurointerventional database was reviewed for identification of all cases of A2 bifurcation aneurysms that were treated with Y-stent configuration. The authors report clinical, technical and outcome data on four patients with pericallosal aneurysms who were treated with a Y-configuration stent-assisted coil embolization technique. RESULTS: A Y-configuration stent placement in the anterior cerebral artery/A2 bifurcation was successfully achieved in all four patients without significant technical difficulties. One patient presented with a previously ruptured and partially treated aneurysm and three patients with incidentally found aneurysms. All four patients had a Y-configuration stent placement in one setting. The Y-configuration allowed for complete occlusion of all four aneurysms with no recurrence or arterial occlusion on mean angiographic follow-up of 13.5 months (6-28). CONCLUSION: Treating wide-neck pericallosal artery aneurysms at the bifurcation with Y-configuration stent placement is feasible and effective. This technique may be considered as a therapeutic option for wide-neck aneurysms that pose a difficult technical challenge.

Small unruptured partially thrombosed aneurysms and stroke: report of three cases and review of the literature.

Several case reports and studies suggest that partially thrombosed large and giant aneurysms are potential sources of distal embolic events. However, there are limited data on small thrombosed aneurysms as a possible cause of ischemic events. Three patients are reported who presented with acute ischemic stroke and in whom the initial imaging studies showed a small (<10 mm), unruptured, partially thrombosed aneurysm. In each case, the aneurysm location was confirmed by a conventional angiogram. In all cases, the aneurysms were found on the proximal middle cerebral artery, in the territory corresponding to the clinical symptoms of the stroke. The mechanism of middle cerebral artery embolic event was thought to be related to the thrombus within the aneurysm, causing subsequent embolization into distal related vascular territory. Two of these patients had craniotomy for aneurysm clipping; one was managed conservatively with medical therapy alone. Thrombosis of small, unruptured intracranial aneurysms should be considered as a possible cause of acute-onset stroke symptoms in patients with acute ischemic stroke. It is under-recognized in the current literature, and no guidelines currently exist for medical or surgical treatment of such aneurysms. Medical management is often decided on an individual basis. Surgical treatment mostly involves aneurysmal clipping rather than coiling.

Endovascular embolization of head and neck tumors.

Endovascular tumor embolization as adjunctive therapy for head and neck cancers is evolving and has become an important part of the tools available for their treatment. Careful study of tumor vascular anatomy and adhering to general principles of intra-arterial therapy can prove this approach to be effective and safe. Various embolic materials are available and can be suited for a given tumor and its vascular supply. This article aims to summarize current methods and agents used in endovascular head and neck tumor embolization and discuss important angiographic and treatment characteristics of selected common head and neck tumors.

Initial experience with the coaxial dual-lumen ascent balloon catheter for wide-neck aneurysm coil embolization.

INTRODUCTION: Techniques for coil embolization of wide-neck cerebral aneurysms include the use of stents and temporary occlusion with compliant non-detachable balloons to safely allow dense packing of the aneurysm lumen with detachable coils. We describe the use of a new balloon device for assisting in wide-neck aneurysm coil treatment. METHODS: A single institution neuroendovascular database was accessed to identify cases in which the Ascent balloon (Codman Neurovascular, Raynham, MA, USA) was used for aneurysm coil embolization. Clinical, demographic, and angiographic data were obtained through chart review. RESULTS: Eleven cerebral aneurysm cases were treated using the Ascent balloon during the first 12-month period that the new device was available at our institution. Three of the patients presented with ruptured aneurysms. All aneurysms were large (maximum diameter 6 mm or greater), with an average maximum diameter of 9.4 mm, and an average neck diameter of 5.5 mm. Complete occlusion with coil embolization (Raymond class I) was achieved in all cases. The Ascent balloon was successfully positioned across the neck of the aneurysm in nine patients. CONCLUSION: This initial experience demonstrates the feasibility and immediate outcomes of the coaxial dual-lumen design Ascent balloon catheter used as an assistive device in coil embolization of wide-neck cerebral aneurysms. This device contributes to the growing number of assistive devices for the treatment of complex cerebral aneurysms.

Pharos neurovascular intracranial stent: elective use for a symptomatic stenosis refractory to medical therapy.

The Warfarin-Aspirin Symptomatic Intracranial Disease study investigators demonstrated that medically managed patients with symptomatic intracranial stenosis experience a 7-11% annual stroke risk. Early treatment efforts utilized balloon-mounted coronary stents, which provided excellent angiographic results (postprocedure stenoses <10%), versus percutaneous transluminal angioplasty (PTA) alone (40%). However, the rigidity of balloon-mounted coronary stents provided limited access to the tortuous cerebrovasculature. Self-expanding stents became available for intracranial stenosis treatment in 2002. With increased flexibility, immediate results were encouraging (approximately 30% residual stenosis). However, midterm results have demonstrated disappointingly high rates of restenosis. To address these issues, the Pharos Neurovascular Stent System (Pharos, Micrus Endovascular, San Jose, CA) was developed. The Pharos is a balloon-expandable stent mounted on a rapid-exchange PTA catheter especially designed for intracranial endovascular applications. Utilizing the Pharos, we obtained an outstanding angiographic result (0% residual stenosis), with no associated morbidity. The patient was discharged home on postprocedure day 1 and remained symptom-free, with no in-stent stenosis, 3 months later. Our experience with the Pharos supports early literature suggesting that this stent may be a valuable treatment option for patients with medically refractory intracranial stenosis.