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BACKGROUND: In cases where mechanical thrombectomy (MT) fails, rescue stenting may be necessary to achieve reperfusion; however, the lack of standardized techniques or devices poses a challenge. This series aims to present our early experience with the Onyx Frontier™ and Resolute Onyx™ balloon-mounted drug-eluting stents for rescue stenting. METHODS: A retrospective chart review was performed of all patients who underwent rescue stenting, in the setting of failed MT, using Onyx Frontier™ or Resolute Onyx™ stents at a single institution. Technical details, procedural complications, and patient outcomes were recorded for each case. RESULTS: Twenty-two Onyx Frontier™ and Resolute Onyx™ stents were deployed in 18 patients undergoing rescue stenting. Stent locations included the middle cerebral artery (36.4%), internal carotid artery (18.2%), vertebral artery (22.7%), and basilar artery (22.7%). The average National Institutes of Health Stroke Scale score before MT was 13.8 (range 0-31). The median initial modified Rankin Scale (mRS) score was zero, while the median mRS score at follow-up was three. Successful reperfusion, as assessed by TICI scores, was achieved in 43.8% of patients for TICI 3, 43.8% for TICI 2C, and 12.5% for TICI 2B. Post-revascularization, 16.7% of patients experienced hemorrhage, of which one patient (5.6%) had symptomatic hemorrhage. CONCLUSIONS: Onyx Frontier™ and Resolute Onyx™ stents are well suited for rescue stenting in cases of failed MT. These balloon-mounted drug-eluting stents exhibit excellent navigability, rendering them appropriate for rescue revascularization procedures. Our findings demonstrate that these stents confer a high degree of technical success.
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Objective Trigeminal neuralgia (TN) is a debilitating syndrome characterized by paroxysmal facial pain in one or more divisions of the trigeminal nerve. The etiology and treatment paradigms are still controversial. The endoscopically-assisted procedure has not yet been described in percutaneous procedures for TN. The aim of this study was to assess the utility and feasibility of endoscopic-assisted percutaneous approaches for trigeminal rhizotomy in TN. Methods This study comprised eight cadaveric sides heads that underwent an endoscopically assisted percutaneous approach using Hakanson's anterior puncture method for targeting the foramen ovale. Results V3 exiting the foramen ovale was easily visualized with the endoscope on all sides. While approaching the foramen ovale, distal branches of V3 such as the lingual and inferior alveolar nerves were first identified as they traveled between the medial and lateral pterygoid muscles. These branches were then traced proximally to the V3 trunk deep to the lateral pterygoid. Large arteries and veins were easily visualized and avoided in the trajectory to the foramen ovale. No gross injury to any neurovascular structure along the course of the needle insertion was identified. Conclusion We found that endoscopic-assisted percutaneous approach to the foramen ovale is feasible and allows for accurate canalization and anatomical identification of the precise location for rhizotomy under direct visualization. Such a procedure, after it is confirmed in patients, could offer a new technique for reducing unsuccessful canalization and could improve outcomes.
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Ventral spinal cord herniation is a rare pathology, caused by a dural defect, that leads to progressive myelopathy. The true prevalence of ventral spinal cord herniation is unknown largely because of underdiagnosis due to its nonspecific symptoms. Though there are theories that attempt to describe how these dural defects are formed, the true causes of these defects are unknown. In this case report, we present a case of a 29-year-old female who had an idiopathic ventral spinal cord herniation causing an intradural hematoma and subarachnoid hemorrhage. This is the first reported case of spinal cord herniation causing hemorrhage.
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Common femoral artery (CFA) transfemoral access (TFA) has been the traditional route for neuroendovascular intervention with flow diversion including the pipeline embolization device (PED) for the treatment of wide-necked aneurysms. Successful deployment requires significant catheter support, thus making alternative access challenging. A 56-year-old-female presented with subarachnoid hemorrhage secondary to a large ruptured posterior communicating artery (PCOM) aneurysm as well as found to have an unruptured left superior cerebellar artery (SCA) aneurysm. Endovascular embolization of PCOM aneurysm via TFA was complicated by a right CFA pseudoaneurysm. The SCA aneurysm was treated 8 weeks later via left TFA with consequent development of a left CFA pseudoaneurysm. Contrasted magnetic resonance angiography revealed recurrence at the neck of the PCOM aneurysm at 4-month follow-up, treated via transradial access (TRA) PED flow diversion to avoid additional groin complications. Anatomic, procedural, and clinical considerations for TRA anterior circulation flow diversion using the PED are reviewed.
