CT perfusion-guided versus time-guided mechanical recanalization in acute ischemic stroke patients.

OBJECTIVE: Perfusion studies are increasingly used to triage acute stroke patients for endovascular recanalization therapies. We compare the safety and efficacy of CT perfusion (CTP)-guided to time-guided mechanical recanalization in acute ischemic stroke (AIS) patients. METHODS: A review was conducted on 132 patients, 94 undergoing CTP-guided and 38 undergoing time-guided (maximum 8h from symptom onset) mechanical recanalization at our institution. RESULTS: The rate of partial-to-complete recanalization did not differ between the CTP and the non-CTP group (78.7% vs. 81.6%, respectively, p=0.71). ICH occurred respectively in 18.1% in the CTP group versus 31.6% in the non-CTP group (p=0.06). The overall in-hospital mortality rate was significantly lower in the CTP group (15.9% vs. 36.8%, p=0.04). In multivariable analysis, CTP-guided patient selection was an independent negative predictor of in-hospital mortality (OR=3.2; p=0.01). CTP-guided patient selection, however, was not a predictor of favorable outcome (Modified Rankin Scale 0-2 or 0-3). CONCLUSIONS: CTP-based patient selection was associated with lower ICH and mortality rates. Favorable outcomes, however, did not differ between the 2 groups. These results may suggest a possible benefit in terms of in-hospital mortality with CTP-guided triage of AIS patients for endovascular treatment.

Endovascular treatment of cerebral dural and pial arteriovenous fistulas.

Dural arteriovenous fistulas (DAVFs) are arteriovenous shunts from a dural arterial supply to a dural venous channel, typically supplied by pachymeningeal arteries and located near a major venous sinus. Pial arteriovenous fistulas (PAVFs) are composed of one or more arterial feeders draining into a single vein in the absence of an intervening nidus. Fistulas manifesting features of high risk for rupture should be treated aggressively, the spectrum of treatment varies from endovascular, surgical resection, and stereotactic radiosurgery. This article describes the natural history, clinical presentation, and treatment of dural and pial fistulas, with emphasis on endovascular treatment.

Comparison of flow diversion and coiling in large unruptured intracranial saccular aneurysms.

BACKGROUND AND PURPOSE: Flow diversion has emerged as an important tool for the management of intracranial aneurysms. The purpose of this study was to compare flow diversion and traditional embolization strategies in terms of safety, efficacy, and clinical outcomes in patients with unruptured, large saccular aneurysms (≥10 mm). METHODS: Forty patients treated with the Pipeline Embolization Device (PED) were matched in a 1:3 fashion with 120 patients treated with coiling based on patient age and aneurysm size. Fusiform and anterior communicating artery aneurysms were eliminated from the analysis. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. RESULTS: There were no differences between the 2 groups in terms of patient age, sex, aneurysm size, and aneurysm location. The rate of procedure-related complications did not differ between the PED (7.5%) and the coil group (7.5%; P=1). At the latest follow-up, a significantly higher proportion of aneurysms treated with PED (86%) achieved complete obliteration compared with coiled aneurysms (41%; P<0.001). In multivariable analysis, coiling was an independent predictor of nonocclusion. Retreatment was necessary in fewer patients in the PED group (2.8%) than the coil group (37%; P<0.001). A similar proportion of patients attained a favorable outcome (modified Rankin Scale, 0-2) in the PED group (92%) and in the coil group (94%; P=0.8). CONCLUSIONS: The PED provides higher aneurysm occlusion rates than coiling, with no additional morbidity and similar clinical outcomes. These findings suggest that the PED might be a preferred treatment option for large unruptured saccular aneurysms.

The Pipeline Embolization Device: learning curve and predictors of complications and aneurysm obliteration.

BACKGROUND: The Pipeline Embolization Device (PED) has emerged as a promising treatment for intracranial aneurysms. OBJECTIVE: To assess the safety and efficacy of the PED, to analyze the effect of operator experience on the complication rate, and to identify predictors of complications and obliteration. METHODS: A total of 109 patients with 120 aneurysms were treated with PED at our institution. The patient population was divided into 3 consecutive equal groups to assess whether overall and major complication rates decreased over time: group 1, patients 1 through 37; group 2, patients 38 through 73; and group 3, patients 74 through 109. RESULTS: The number of PEDs used was 1.40 per aneurysm. Symptomatic and major procedure-related complications occurred in 11% and 3.7% of patients, respectively. The rate of complications decreased from 16.2% in group 1 to 5.6% in group 3, and the rate of major complications fell dramatically from 10.8% in group 1 to 0% in groups 2 and 3 (P < .05). Procedure time significantly decreased over time (P = .04). In multivariate analysis, previously treated aneurysms were predictive of procedural complications (P = .02). At the latest follow-up, 65.8% of aneurysms were completely occluded, 9.6% were nearly completely occluded, and 24.6% were incompletely occluded. In multivariate analysis, fusiform aneurysms (P = .05) and shorter angiographic follow-up (P = .03) were negative predictors of aneurysm obliteration. CONCLUSION: PED therapy may have an acceptable safety-efficacy profile. The risk of complications appears to decrease dramatically with physician experience, supporting the existence of a learning curve. Patients with previously treated aneurysms have higher complication rates, whereas fusiform aneurysms achieve lower obliteration rates.

Stent-assisted coiling of intracranial aneurysms: predictors of complications, recanalization, and outcome in 508 cases.

BACKGROUND AND PURPOSE: Self-expanding stents are increasingly used for treatment of complex intracranial aneurysms. We assess the safety and the efficacy of intracranial stenting and determine predictors of treatment outcomes. METHODS: A total of 508 patients with 552 aneurysms were treated with Neuroform and Enterprise stents between 2006 and 2011 at our institution. A multivariate analysis was conducted to identify predictors of complications, recanalization, and outcome. RESULTS: Of 508 patients, 461 (91%) were treated electively and 47 (9%) in the setting of subarachnoid hemorrhage. Complications occurred in 6.8% of patients. In multivariate analysis, subarachnoid hemorrhage, delivery of coils before stent placement, and carotid terminus/middle cerebral artery aneurysm locations were independent predictors of procedural complications. Angiographic follow-up was available for 87% of patients at a mean of 26 months. The rates of recanalization and retreatment were, respectively, 12% and 6.4%. Older age, previously coiled aneurysms, larger aneurysms, incompletely occluded aneurysms, Neuroform stent, and aneurysm location were predictors of recanalization. Favorable outcomes were seen in 99% of elective patients and 51% of subarachnoid hemorrhage patients. Patient age, ruptured aneurysms, and procedural complications were predictors of outcome. CONCLUSIONS: Stent-assisted coiling of intracranial aneurysms is safe, effective, and provides durable aneurysm closure. Higher complication rates and worse outcomes are associated with treatment of ruptured aneurysms. Stent delivery before coil deployment reduces the risk of procedural complications. Staging the procedure may not improve procedural safety. Closed-cell stents are associated with significantly lower recanalization rates.

Treatment of posterior circulation aneurysms with the pipeline embolization device.

BACKGROUND: Treatment of complex intracranial aneurysms with the pipeline embolization device (PED) has become common practice in neurovascular centers. Very few studies have assessed the safety and efficacy of PED treatment for posterior circulation aneurysms. OBJECTIVE: To retrospectively present our experience with use of the PED in the posterior circulation. METHODS: A total of 7 patients harboring 7 posterior circulation aneurysms were treated with the PED at our institution between November 2011 and July 2012. RESULTS: Aneurysm size was 14.1 mm on average. All patients had unruptured aneurysms. Three aneurysms arose from the vertebral artery, 2 from the basilar artery, and 2 from the vertebrobasilar junction. A single stent was used in 4 patients, 2 stents in 2 patients, and 3 stents in 1 patient. Treatment was successful in all 7 patients. No procedural complications or perforator infarcts were noted in the series. No patient experienced new neurological symptoms related to PED treatment during the follow-up period. Angiographic follow-up was available for 6 patients at a mean time point of 5.5 months. Follow-up angiography showed 100% aneurysm occlusion in 3 patients, marked decrease in aneurysm size in 2 patients, and no change in 1 patient. CONCLUSION: In our initial experience, it appears that PED treatment in select patients with vertebrobasilar aneurysms may have a reasonable safety-efficacy profile. Larger studies are needed to confirm our findings.

Single center experience with pipeline stent: feasibility, technique, and complications.

BACKGROUND: Endovascular coil embolization is an established method of treatment for intracranial aneurysms. The pipeline embolization device (PED) is a low-porosity endovascular stent designed to reconstruct the parent artery and decrease blood flow into the aneurysm. OBJECTIVE: To report a series of 36 patients treated with the PED. METHODS: Thirty-six patients underwent PED placement for aneurysm at the Jefferson Hospital for Neuroscience from October 2010 to November 2011. Clinical charts were reviewed. RESULTS: Thirty-six patients with 42 aneurysms were treated (3 male; 33 female; ages, 34-82; mean age, 60.1 years). Forty-one aneurysms were located in the anterior circulation, whereas one was located at the vertebrobasilar junction. PED placement was successful in all patients and resulted in stasis within all treated aneurysms. Symptomatic postoperative complications were witnessed in 13.9% (n = 5) of patients. These complications included intracerebral hemorrhage (n = 4), dissection (n = 1), symptomatic stroke (n = 2), and death (n = 1). CONCLUSION: Treatment of simple or complex intracranial aneurysms with PEDs alone or in conjunction with coil embolization is technically feasible, and the deployment technique requires a high degree of endovascular skills. Major perioperative adverse events must be studied. Respect for the indications of the procedure is crucial to justify the risk.

The superior ophthalmic vein approach for the treatment of carotid-cavernous fistulas: a novel technique using Onyx.

OBJECT: Endovascular therapy is the primary treatment option for carotid-cavernous fistulas (CCFs). Operative cannulation of the superior ophthalmic vein (SOV) provides a reasonable alternative route to the cavernous sinus when all transvenous and transarterial approaches have been unsuccessful. The role of the liquid embolic agent Onyx in the management of CCFs has not been well documented, especially when using an SOV approach. The purpose of this study is to assess the safety and efficacy of Onyx embolization of CCFs through a surgical cannulation of the SOV. METHODS: The authors retrospectively reviewed all patients with CCFs who were treated with Onyx through an SOV approach between April 2009 and April 2011. Traditional endovascular approaches had failed in all patients. RESULTS: A total of 10 patients were identified, 1 with a Type A CCF, 5 with a Type B CCF, and 4 with a Type D CCF. All fistulas were embolized in 1 session. Onyx was the sole embolic agent used in 7 cases and was combined with coils in 3 other cases. Complete obliteration was achieved in 8 patients and a significant reduction in fistulous flow was achieved in 2 patients, which later progressed to near-complete occlusion on angiographic follow-up. All patients experienced a complete clinical recovery with excellent cosmetic results and were free from recurrence at their latest clinical follow-up evaluations. CONCLUSIONS: Onyx embolization is an excellent therapy for CCFs in general, and through an SOV approach in particular. Direct operative cannulation of the SOV followed by Onyx embolization may be the best treatment option in patients with CCFs when all other endovascular approaches have been exhausted.

Moyamoya disorder in the United States.

BACKGROUND: In Asian populations, moyamoya disease has a well-defined phenotype including a bimodal age of presentation with children typically presenting with ischemic phenomena and adults presenting with hemorrhage. Studies have provided evidence that moyamoya disease in the United States may exhibit a different phenotype. OBJECTIVE: To assess overall rates of admission, demographics, procedures, and outcomes of patients admitted or diagnosed with moyamoya disorder in US hospitals. METHODS: A comprehensive assessment of the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (2002-2008) was performed. Patient demographics, comorbidities, procedures, and outcomes were analyzed. RESULTS: There were 2280 admissions for moyamoya disorder with a predicted national estimate of 11 163 admissions (0.57/100 000 persons/y). Over time, there was a significant increase in diagnosis and associated ischemic strokes. Females (72%) were affected more than males (28%). Demographics included white (49%), black (24%), Hispanic (11%), Asian (11%), and other (3.3%). Mean age at presentation was 31.6 ± 18.0. Children were significantly more likely to be diagnosed with ischemic phenomena (16.4%) than hemorrhage (3.3%), as were adults (18.8% vs 11.0%). Status at discharge was largely routine (74.8%) vs short-term hospital (3%), home health care (7%), transfer to another hospital (12%), or in-hospital death in 2.3%. CONCLUSION: Patients admitted to US hospitals diagnosed with moyamoya disorder were more commonly female and white, and both adults and children were more likely to be diagnosed with ischemic vs hemorrhagic stroke. Over time, there was an increase in diagnosis, associated ischemic stroke, and treatment with extracranial-intracranial bypass.

Redefining Onyx HD 500 in the Flow Diversion Era.

We report the largest US case series results using Onyx HD-500 (EV3), a new liquid embolic agent, in the successful treatment of 21 patients with wide-neck intracranial aneurysms (mean size 4.5 mm), which are at increased risk of incomplete occlusion or recanalization with standard endovascular intervention utilizing detachable platinum coils. All aneurysms were located in the anterior circulation, and three aneurysms presented as acute subarachnoid hemorrhages. Complete aneurysm occlusion was present in 19 of 21 patients (90%). On six-month followup, one patient with an initially small residual neck progressed to total occlusion. Aneurysm recanalization was not detected in any patients on mean follow up of 8.9 months in 11 patients. Four patients experienced transient neurologic deficits in the immediate postoperative period and one in a delayed fashion. Embolization with the liquid embolic agent Onyx appears to be a safe and effective endovascular modality of treatment for wide-neck aneurysms or recurrent aneurysms that had previously failed treatment with detachable coils.

Management of incidental cavernous malformations: a review.

Cavernous malformations (CMs) are angiographically occult vascular malformations that are frequently found incidentally on MR imaging. Despite this benign presentation, these lesions could cause symptomatic intracranial hemorrhage, seizures, and focal neurological deficits. Cavernomas can be managed conservatively with neuroimaging studies, surgically with lesion removal, or with radiosurgery. Considering recent studies examining the CM's natural history, imaging techniques, and possible therapeutic interventions, the authors provide a concise review of the literature and discuss the optimal management of incidental CMs.

Management of incidentally discovered intracranial vascular abnormalities.

With the widespread use of brain imaging studies, neurosurgeons have seen a marked increase in the number of incidental intracranial lesions, including vascular abnormalities. Specifically, the detection of incidentally discovered aneurysms, arteriovenous malformations, cavernous angiomas, developmental venous anomalies, and capillary telangiectasias has increased. The best management strategy for most of these lesions is controversial. Treatment options include observation, open surgery, endovascular procedures, and radiosurgery. Multiple factors should be taken into account when discussing treatment indications, including the natural history of the disease and the risk of the treatment. In this article, the authors focus on the natural history of these lesions and the risk of the treatment, and they give recommendations regarding the most appropriate management strategy based on the current evidence in the literature and their experience with intracranial vascular abnormalities.

Pilomatrix carcinoma of the thoracic spine: case report and review of the literature.

CONTEXT: Pilomatrixoma is a common head and neck neoplasm in children. Its malignant counterpart, pilomatrix carcinoma, is rare and found more often in men. METHOD: Case report of a 21-year-old man with pilomatrixoma of the thoracic spine that underwent malignant degeneration to pilomatrix carcinoma. FINDINGS: The appearance of a painless mobile axillary mass was followed by severe back pain 1 year later. Imaging revealed a compression fracture at the T5 level. The patient underwent resection of the axillary mass and spinal reconstruction of the fracture; the pathology was consistent with synchronous benign pilomatrixomas. Three months later he presented with a recurrence of the spinal lesion and underwent further surgical resection; the pathology was consistent with pilomatrix carcinoma. He received adjuvant radiotherapy and at his 1-year follow-up examination had no sign of recurrence. CONCLUSION/CLINICAL RELEVANCE: Pilomatrix carcinoma involving the spine is a rare occurrence. It has a high incidence of local recurrence, and wide excision may be necessary to reduce this risk. Radiotherapy may be a helpful adjuvant therapy. Clinicians should be aware of this entity because of its potential for distant metastasis.