Endovascular occlusion of pial arteriovenous macrofistulae, using pCANvas1 and adenosine-induced asystole to control nBCA injection.

Background In large-caliber pial macrofistulae (pMF), the combination of high blood flow velocity and large efferent artery diameter makes control over the endovascular vessel occlusion difficult and may result in the inadvertent venous passage of occlusive devices or embolic agents. Case descriptions Patient 1: A 27-year-old man presented with headache and ataxia. An infratentorial pMF supplied by both superior cerebellar arteries with venous ectasia was found. The first treatment attempt using balloons and coils failed since the position of either device could not be controlled because of a distal diameter of the feeding artery of 8 mm. In a second session a pCANvas1 (phenox) was deployed at the level of the arteriovenous connection and adenosine-induced asystole allowed the controlled injection of nBCA/Lipiodol with partial occlusion of the pMF. A remaining arteriovenous shunt was occluded under asystole in a third session. The procedures were well tolerated, the patient returned to normal and DSA confirmed the occlusion of the fistula. Patient 2: A 13-year-old boy with hereditary hemorrhagic teleangiectasia presented with an intracerebral hemorrhage from an aneurysm of the left MCA. Twelve weeks after the aneurysm treatment a feeding MCA branch (diameter 4.5 mm) of a right frontal pMF was catheterized. The macrofistula was occluded by deployment of a pCANvas1, followed by the injection of nBCAl/Lipiodol under adenosine-induced asystole. Conclusion pCANvas1 and adenosine-induced asystole allow a controlled injection of nBCA/Lipiodol for the endovascular occlusion of high-flow pMF without venous passage of the embolic agent.

Oclusión arterial de gran vaso diagnosticada por angiografía portomografía computarizada en el ictus isquémico agudo: frecuencia, factores predictores y seguridad / Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: frequency, predictive factors, and safety

Introducción: Con la creciente disponibilidad de las terapias endovasculares, la demostración de oclusión arterial en el ictus isquémico agudo ha cobrado mayor relevancia. Este estudio evalúa la frecuencia de oclusión arterial y los factores asociados a la misma, así como las complicaciones derivadas del uso de angio-TC en el ictus agudo. Métodos: Se analizan retrospectivamente a los pacientes con ictus isquémico entre el 1 de julio y el 31 de diciembre del 2011. Resultados: Ciento cincuenta y siete pacientes (edad media de 74±11 años, NIHSS 5 [2-13]). Un 56,7% llegó al hospital con menos de 8 h de evolución. Se realizó angio-TC en 71 casos (45,2%), detectando oclusión de gran vaso en 37 (52,1%). La localización más frecuente fue M1 (40%). En el análisis univariante se halló asociación de la escala NIHSS (17 vs. 7, p < 0,001) y la fibrilación auricular (64% vs. 32%, p = 0,006) con la presencia de oclusión arterial. Posteriormente, se realizó una regresión logística, confirmando dicha asociación. No se observó ningún caso de nefropatía por contraste. El tiempo puerta-aguja para fibrinólisis intravenosa fue de 61,2 ± 24,5 min en los pacientes en que se realizó angio-TC y 53,5 ± 34,3 en los que no se realizó (p = 0,495). Conclusiones: La oclusión de gran vaso se detecta en el 23,6% de la muestra, especialmente en los pacientes traídos en las primeras horas. La escala NIHSS es un buen factor predictor

Introduction: Demonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke. Methods: We retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and-December 2011. Results: We included 157 patients (mean age, 74 ± 11; mean NIHSS score, 5 [2-13]). Of that total, 56.7% of the patients were admitted to hospital during the first 8 hours. CT-angiography was performed in 71 cases (45.2%); arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P < .001) and atrial fibrillation (64% vs 32%, P = .006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming theseassociations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2 ± 24.5 minutes in patients who underwent CT-angiography, and 53.5±34.3 minutes in those who did not (P = .495). Conclusions: Arterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor

Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: frequency, predictive factors, and safety.

INTRODUCTION: Demonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke. METHODS: We retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and-December 2011. RESULTS: We included 157 patients (mean age, 74±11; mean NIHSS score, 5 [2-13]). Of that total, 56.7% of the patients were admitted to hospital during the first 8hours. CT-angiography was performed in 71 cases (45.2%); arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P<.001) and atrial fibrillation (64% vs 32%, P=.006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming these associations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2±24.5minutes in patients who underwent CT-angiography, and 53.5±34.3minutes in those who did not (P=.495). CONCLUSIONS: Arterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor.

Estenosis crítica de arteria basilar asociada a inestabilidad clínica: propuesta de una nueva indicación de tratamiento endovascular agudo / Critical stenosis of the basilar artery associated with clinical instability: new proposed indication for acute endovascular treatment

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Patient radiation dose management in the follow-up of potential skin injuries in neuroradiology.

BACKGROUND AND PURPOSE: Radiation exposure from neurointerventional procedures can be substantial, with risk of radiation injuries. We present the results of a follow-up program applied to potential skin injuries in interventional neuroradiology based on North American and European guidelines. MATERIALS AND METHODS: The following guidelines approved in 2009 by SIR and CIRSE have been used over the last 2 years to identify patients with potential skin injuries requiring clinical follow-up: peak skin dose >3 Gy, air kerma at the patient entrance reference point >5 Gy, kerma area product >500 Gy · cm(2), or fluoroscopy time >60 minutes. RESULTS: A total of 708 procedures (325 in 2009 and 383 in 2010) were included in the study. After analyzing each dose report, 19 patients (5.9%) were included in a follow-up program for potential skin injuries in 2009, while in 2010, after introducing several optimizing actions and refining the selection criteria, only 4 patients (1.0%) needed follow-up. Over the last 2 years, only 3 patients required referral to a dermatology service. CONCLUSIONS: The application of the guidelines to patient radiation dose management helped standardize the selection criteria for including patients in the clinical follow-up program of potential skin radiation injuries. The peak skin dose resulted in the most relevant parameter. The refinement of selection criteria and the introduction of a low-dose protocol in the x-ray system, combined with a training program focused on radiation protection, reduced the number of patients requiring clinical follow-up.

El acceso arterial humeral: una vía alternativa al acceso femoral en el tratamiento endovascular del ictus agudo / Humeral arterial access: an alternative route to the femoral artery in the endovascular treatment of acute stroke

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[From the evidence to the organisation of stroke care]. / De la evidencia a la organización de la atención al ictus.

INTRODUCTION: Acute stroke care in stroke units (SU) compared to care in general medicine wards provides benefits to the patient. DEVELOPMENT: Acute stroke care in an SU has shown benefits in reducing mortality, institutionalisation, dependency and costs compared to care in internal medicine wards, and even a lower risk of recurrence in the long term. The benefits are associated with specific treatments developed in the SU, such as thrombolytic therapy, development of clinical pathways, standardised procedures, and training and experience of professionals in the SU. This evidence should lead to the proper organisation of hospitals to ensure that all acute stroke patients may benefit from care in an SU. The introduction of SUs is a priority in Europe, although the number of stroke patients admitted to SUs is still low. CONCLUSIONS: Based on current evidence, acute stroke patients should be cared for in an SU due to the associated clinical benefits and hospitals should organise to provide this care to patients.

[Endovascular treatment for acute stroke: an open field to begin]. / Tratamiento endovascular del ictus agudo: un campo muy abierto que está por iniciar.

INTRODUCTION: The evidence that recanalization and reperfusion of the distal vascular bed in appropriately selected patients is crucial to achieve good functional outcome has triggered interest and research into endovascular treatment of acute ischemic stroke. DEVELOPMENT: Intravenous (iv) thrombolytic therapy is the treatment of choice in patients with acute ischemic stroke, however, it has certain limitations. Endovascular treatment is a promising alternative with theoretical advantages over iv therapy, such as an increased frequency of recanalization and longer therapeutic windows. Endovascular reperfusion strategies include intra-arterial fibrinolysis with drugs, or endovascular mechanical devices for thrombectomy or thrombus disruption, thromboaspiration, or thrombus entrapment in the vessel wall. The ideal of comprehensive treatment of acute stroke would provide specificity to treat an individual patient: with specific arterial occlusion and collaterals and a determined physiology of acute cerebral ischemia. With all this information, we would decide the best therapeutic strategy for the patient, and move from just a time-based approach to include a pathophysiology approach as well, and thus different patients could have different therapeutic windows. The endovascular treatment situation in Spain is heterogeneous and requires human and material resources to enable it to be implemented throughout the country. CONCLUSIONS: Endovascular treatment of stroke is a new therapeutic tool for achieving reperfusion safely in patients ineligible for Alteplase or who have failed reperfusion with an iv fibrinolytic.