Penetrating intracranial trauma of two minors treated with endovascular technique with the use of temporary balloon occlusion for proximal arterial control.

We present two children treated with endovascular techniques to gain proximal arterial control of the internal carotid and vertebral artery prior to removal of penetrating objects from the skull base. Both siblings (8-month-old and 22-month-old boys) were injured by different sharp objects (knife and scissor) by a guardian. They were transported to the emergency room where vascular control, including coil embolisation and internal carotid balloon occlusion, was performed in the neuroendovascular suite for safe removal of penetrating objects. Both minors recovered and were discharged home without any focal neurological deficits. In two children with scissor and knife stab with intracranial penetration, endovascular technique allowed safe removal of objects and ensured proximal arterial control was maintained to control for possible extravasation of blood on removal from the skull base.

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.

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.

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.

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.

Rationale for treating unruptured intracranial aneurysms: actuarial analysis of natural history risk versus treatment risk for coiling or clipping based on 14,050 patients in the Nationwide Inpatient Sample database.

OBJECTIVE: The treatment of small unruptured intracranial aneurysms has been questioned based on the results of the International Study of Unruptured Intracranial Aneurysms. Our objective was to compare natural history rupture risk versus treatment risk for coiling and clipping small unruptured aneurysms using data in the Nationwide Inpatient Sample database. METHODS: Data for clipping and coiling of unruptured aneurysms was collected from the Nationwide Inpatient Sample from 2002-2008. Treatment risks were adjusted for age, gender, and medical comorbidities. Logistic regression models were used to create curves depicting the estimated probability of poor outcome as a function of patient age for clipping and coiling. These treatment risk curves were compared against natural history actuarial risk curves calculated from four prominent studies. RESULTS: There were 14,050 hospitalizations: 7439(53%) coiling; 6611(47%) clipping. For patients who underwent coiling or clipping, the mortality rate was 2.17% and 2.66%, and the morbidity rate was 2.16% and 4.75%, respectively. The adjusted risk of poor outcome from clipping and coiling, when modeled against most natural history studies, demonstrates a treatment benefit for clipping for patients <70 years and for coiling patients <81 years. Models using the International Study of Unruptured Intracranial Aneurysms data demonstrate a treatment benefit for clipping for patients <61 years and for coiling for patients <70 years. CONCLUSIONS: Both clipping and coiling of unruptured intracranial aneurysms are safe. This analysis demonstrates rationale for clipping small unruptured aneurysms in patients <61-70 years and coiling small unruptured aneurysms in patients <70-80 years. Treatment beyond these age ranges is associated with increased risk of poor outcome.

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.

Nonaneurysmal subarachnoid hemorrhage: an update.

Nonaneurysmal subarachnoid hemorrhage (NA-SAH) constitutes a heterogeneous group of patients, both perimesencephalic (PMN-SAH) and non-perimesencephalic (nPMN-SAH). Despite many reports and case series, the etiology of NA-SAH remains uncertain. The differences in clinical course and outcome between PMN-SAH and nPMN-SAH are evident and have to be taken into consideration at the time of admission, as aggressive diagnostic evaluation and management are required for latter patient. In terms of diagnostic evaluation, the most important determination is to differentiate PMN-SAH from nPMN-SAH and aneurysmal SAH. PMN-SAH can be distinguished on CT in the majority of patients, but should be confirmed by a negative cerebral angiography. In addition, Convexal NA-SAH is another important subtype of NA-SAH associated with diverse etiologies and symptoms, although prognosis is generally favorable.

Intentional partial coiling dome protection of complex ruptured cerebral aneurysms prevents acute rebleeding and produces favorable clinical outcomes.

BACKGROUND: The coiling of ruptured cerebral aneurysms protects against acute rebleeding; however, whether partially coiling a ruptured cerebral aneurysm protects against acute rebleeding has never been demonstrated. OBJECTIVE: This study was performed to test our hypothesis that intentional partial coiling of complex ruptured cerebral aneurysms, which are unfavorable for clipping and cannot be completely coiled primarily, prevents acute rebleeding to allow for clinical and neurological recovery until definitive treatment and produces favorable clinical outcomes. METHODS: Data were collected from the prospective databases of three centers. Only subarachnoid hemorrhage patients that were treated with a strategy of intentional partial coiling for dome protection were included. This did not include patients in whom the goal was complete coiling but only subtotal coil occlusion was achieved. RESULTS: Fifteen patients [aged 51 ± 13 years; HH 3-5 (n = 7); Fisher 3-4 (n = 9)] were treated with intentional partial dome protection. Aneurysm size was 12.8 ± 5.4 mm; neck size 4.9 ± 3 mm; 12 anterior circulation. Four intentional partial coilings were performed with balloon assistance. Definitive treatment was performed 92 ± 90 days later, with no case of rebleeding. Definitive treatment was clipping (n = 8), stent-coiling (n = 5), Onyx (n = 1), further coiling (n = 1). Clinical outcome was favorable in 13 cases (GOS 4-5), fair in one (GOS 3), and death in one (GOS 1). CONCLUSIONS: Judicious use of a treatment strategy of intentional partial dome protection for complex aneurysms that are not favorable for clipping and in which complete coiling primarily is not possible may prevent acute rebleeding and produce favorable clinical outcomes.

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.

Stent-associated flow remodeling causes further occlusion of incompletely coiled aneurysms.

BACKGROUND: Incomplete coil occlusion is associated with increased risk of aneurysm recurrence. We hypothesize that intracranial stents can cause flow remodeling, which promotes further occlusion of an incompletely coiled aneurysm. OBJECTIVE: To study our hypothesis by comparing the follow-up angiographic outcomes of stented and nonstented incompletely coiled aneurysms. METHODS: From January 2006 through December 2009, the senior author performed 324 initial coilings of previously untreated aneurysms, 145 of which were Raymond classification 2 and 3. Follow-up angiographic studies were available for 109 of these aneurysms (75%). Angiographic outcomes for stented vs nonstented incompletely coiled aneurysms were compared. A multivariate analysis was performed to identify factors related to the progression of occlusion at follow-up, with adjustment for aneurysm location, size, neck size, Hunt-Hess grade, stent use, initial Raymond score, packing density, age, sex, and medical comorbidities. RESULTS: Of the 109 aneurysms, 37 were stented and 72 were not stented. With a median follow-up time of 15.4 months, 33 stented aneurysms (89%) progressed to complete occlusion compared with 29 nonstented aneurysms (40%). Recanalization rates were lower in the stented group (8.1%) compared with the nonstented group (37.5%; P < .001). On multivariate analysis, stent use (odds ratio, 18.5; 95% confidence interval, 4.3-76.9) and packing density (odds ratio, 1.093; 95% confidence interval, 1.021-1.170) were significant predictors of the progression of occlusion. Aneurysm size was negatively correlated with the progression of occlusion (odds ratio, 0.844; 95% confidence interval, 0.724-0.983). CONCLUSION: Stent-assisted coiling causes progression of occlusion, possibly by a flow remodeling effect. The odds of progression of occlusion of stent-coiled aneurysms were 18.5 times that of nonstented aneurysms.

Acute intraprocedural thrombus formation during wingspan intracranial stent placement for intracranial atherosclerotic disease.

BACKGROUND: Treatment of intracranial atherosclerotic disease with the Wingspan-Gateway intracranial stent and balloon angioplasty system has been reported in several multicenter registries. To date, the incidence of acute intraprocedural thrombus formation during Wingspan stent placement has not been reported. OBJECTIVE: We reviewed the incidence of acute thrombus formation, treatment, and outcome for patients who underwent Wingspan stent placement by the senior author (B.L.H.) between June 2006 and April 2009. METHODS: We routinely perform angiograms every 10 minutes for at least 30 minutes after placement of a Wingspan stent to check for acute thrombus formation. Acute thrombus was graded: (1) visible thrombus but not flow limiting, (2) visible and flow-limiting thrombosis, and (3) complete stent occlusion. Recanalization was graded according to Thrombosis In Myocardial Infarction score. RESULTS: Forty-one patients underwent Wingspan stent placement for intracranial stenosis. Acute intraprocedural thrombus formation developed in 6 (14.6%) within 20 minutes after stent placement: 3 grade 1, 1 grade 2, and 2 grade 3. All 6 were successfully recanalized with Thrombosis In Myocardial Infarction score 3 after intravenous abciximab with or without intra-arterial tissue plasminogen activator and/or balloon angioplasty. There was no morbidity, and all 6 patients were discharged home at their neurological baseline. CONCLUSION: We recommend serial angiography every 10 minutes for at least 30 minutes after placement of Wingspan stents. Once detected, acute thrombosis can be successfully treated with intravenous abciximab with or without intra-arterial tissue plasminogen activator and/or balloon angioplasty.

Length of stay and total hospital charges of clipping versus coiling for ruptured and unruptured adult cerebral aneurysms in the Nationwide Inpatient Sample database 2002 to 2006.

BACKGROUND AND PURPOSE: We have previously reported the difference in length of stay and hospital charges for patients with cerebral aneurysms treated with either clipping or coiling at our institution. We now report an analysis of the same comparison at a national level conducted using the Nationwide Inpatient Sample database. METHODS: We obtained the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project, Agency for Healthcare Quality and Research. The Nationwide Inpatient Sample is the largest all-payer inpatient care database in the US and represents approximately 20% of all inpatient admissions to US nonfederal hospitals. Hospitalizations for clipping or coiling of ruptured and unruptured cerebral aneurysms from 2002 to 2006 were identified by cross-matching International Classification of Diseases-9 codes for diagnoses of subarachnoid hemorrhage (430) or unruptured cerebral aneurysm (437.3) with procedure codes for clipping (39.51) or coiling (39.79, 39.72, or 39.52) of cerebral aneurysms. Length of hospital stay and total hospital charges for clipping and coiling were compared using linear mixed models adjusted for the following patient and hospital-specific factors: gender, age, race/ethnicity, admission source and type, median income level in patient's postal code of residence, payer for care, comorbidities, and hospital cerebral aneurysm case volume, bed size, teaching status, rural/urban location, and geographic region. RESULTS: There were 9635 hospitalizations for ruptured aneurysm treatments (6019 clipping, 3616 coiling) and 9399 hospitalizations for unruptured aneurysm treatments (4700 clipping, 4699 coiling). For ruptured aneurysm patients, after adjusting for the effects of patient-specific and hospital-specific factors, clipping compared to coiling was associated with significantly longer length of stay (P<0.0001) and significantly higher total hospital charges (P<0.0001). For unruptured aneurysm patients, clipping compared to coiling was associated with significantly longer length of stay (P<0.0001) and significantly higher total hospital charges (P<0.0001). After adjusting for the effects of hospital-level and patient-level characteristics, clipping as compared to coiling was associated with an average of 1.2-times more days in hospitalization for ruptured patients and was associated with an average of 1.8-times more days in hospitalization for unruptured patients. On average, clipping resulted in $15,325 more in total charge for ruptured patients and resulted in $11,263 more in total charge for unruptured patients after considering all relevant hospital and patient characteristics. CONCLUSIONS: The results of this nationwide analysis differed from the findings of our single institution study. Clipping compared to coiling was associated with significantly longer lengths of stay and significantly higher total hospital charges for both ruptured and unruptured aneurysm patients.

Timing of aneurysm surgery: the International Cooperative Study revisited in the era of endovascular coiling.

OBJECTIVE: The International Cooperative Study on the Timing of Aneurysm Surgery demonstrated that subarachnoid hemorrhage (SAH) patients who underwent surgery on post-hemorrhage days 4-10 had worse outcomes than patients treated on days 0-3 and days 11-14. Based on these findings, it was concluded that patients who present with SAH on days 4-10 should have aneurysm surgery delayed until after day 10. Since the study, coiling has become a treatment option and it is unclear whether these results apply to this new treatment modality. Our institution is a regional referral center for SAH, and patients are transferred at different time points after hemorrhage. We wanted to determine whether patients that arrive on days 4-10 were safe to undergo coiling immediately rather than waiting until after day 10. METHODS: We reviewed 119 consecutive SAH patients who underwent coiling between January 2006 and June 2008. Factors of age, gender, Hunt-Hess grade, Fisher score, aneurysm size and aneurysm location were included in a regression analysis to determine the effect of day of coiling on clinical outcome at discharge. RESULTS: Of 119 study patients, 86% had coiling on post-hemorrhage days 0-3, and 12% on days 4-10. Patients in these cohorts did not differ in any demographic factors. Age and Hunt-Hess grade were the only predictors of mortality (age p=0.0001, Hunt-Hess p=0.0110) and poor outcome, defined as death or discharge to a skilled nursing facility (age p=0.0001, Hunt-Hess p=0.0001). Day of coiling had no effect on mortality (p=0.5731) or poor outcome (p=0.1861). CONCLUSIONS: Coiling of ruptured aneurysms can be performed safely on patients who arrive on post-hemorrhage days 4-10, and treatment need not be delayed after day 10, as the results of the Timing of Aneurysm Surgery Study initially suggested.