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1.
J Stroke Cerebrovasc Dis ; : 104836, 2020 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-32414581

RESUMO

INTRODUCTION: Effectiveness of mechanical thrombectomy for mild-deficit stroke due to large-vessel occlusion is controversial. We present a single-center consecutive case series on thrombectomy for large-vessel occlusion mild stroke. We evaluated various thrombectomy parameters to better understand disagreement in the literature. METHODS: Data from a retrospective cohort of large-vessel occlusion mild stroke patients (National Institutes of Health Stroke Scale <6) treated with mechanical thrombectomy over 6 years and 2 months were analyzed. Patients were divided into 2 groups: successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b or 3) and failed reperfusion (modified Thrombolysis in Cerebral Infarction 0,1, or 2a). Ninety-day modified Rankin Scale in-hospital mortality, and symptomatic hemorrhage rates were compared between groups. Multivariate logistic regression was performed to evaluate reperfusion status as a predictor of 90-day favorable (modified Rankin Scale 0-2) and excellent (modified Rankin Scale 0-1) outcomes. RESULTS: We identified 61 patients with large-vessel occlusion mild stroke who underwent thrombectomy. Reperfusion was successful in 49 patients and a failure in 12. The successful group exhibited significantly higher rates of favorable outcome (83.7% vs. 25.0%; p < 0.001) and excellent outcome (69.4% vs.16.7%; p = 0.002) at 90 days. In-hospital mortality was significantly higher in the failure group (41.7% vs.10.2%; p = 0.019). Multivariate logistic regression identified successful reperfusion as a significant predictor (p = 0.001) of 90-day favorable outcome. CONCLUSION: Reperfusion success was significantly associated with improved functional outcomes in large-vessel occlusion mild stroke mechanical thrombectomy. Future studies should consider reperfusion rates when evaluating the effectiveness of thrombectomy against that of medical management in these patients.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32372085

RESUMO

BACKGROUND: Instantaneous wave-free ratios (iFRs) are functional measures of arterial stenosis that have become essential to interventional cardiology procedures. Their use for intracranial submaximal angioplasty (angioplasty with an undersized balloon) has not been studied extensively. OBJECTIVE: To describe the feasibility and technique of iFR measurement for stenosis assessment during intracranial angioplasty. METHODS: We present a series of consecutive patients treated between January 1, 2017 and June 30, 2018 with submaximal intracranial angioplasty in whom pre- and postprocedure iFR measurements were obtained with a Verrata-Volcano pressure wire (Philips, Amsterdam, The Netherlands). We collected patient data on age, sex, comorbid conditions, presenting complaints, modified Rankin scale (mRS) score at admission, neurological findings, procedure duration, fluoroscopy time, intraprocedural complications, length of hospital stay, and mRS score at last clinical follow-up (favorable outcome, 0-2). Angiographic stenosis severity and iFR values were recorded before and after angioplasty. RESULTS: A total of 12 patients underwent iFR-guided angioplasty during the study period. The median patient age was 69.5 yr (range 48-81 yr). All patients had symptomatic intracranial arterial stenosis (3-basilar, 2-vertebral, 6-middle cerebral, 1-internal carotid). Preangioplasty stenosis ranged from 55% to 90%. The median postangioplasty reduction in stenosis was 17% (range 9%-30%). Preangioplasty values ranged from 0.30 to 0.40 (n = 4). Postangioplasty values ranged from 0.6 to 0.9 (n = 5). iFR values improved considerably in all patients. No procedure-related complications occurred. The median follow-up was 8.9 mo (range 3-25 mo). Follow-up outcomes were favorable in 10 patients. CONCLUSION: iFR measurement before and after intracranial angioplasty is feasible. It may be used to assess the adequacy of intracranial angioplasty.

3.
Neurosurgery ; 2020 May 11.
Artigo em Inglês | MEDLINE | ID: mdl-32392300

RESUMO

BACKGROUND: Three-dimensional (3D) printing has revolutionized training, education, and device testing. Understanding the design and physical properties of 3D-printed models is important. OBJECTIVE: To systematically review the design, physical properties, accuracy, and experimental outcomes of 3D-printed vascular models used in neurointervention. METHODS: We conducted a systematic review of the literature between January 1, 2000 and September 30, 2018. Public/Publisher MEDLINE (PubMed), Web of Science, Compendex, Cochrane, and Inspec databases were searched using Medical Subject Heading terms for design and physical attributes of 3D-printed models for neurointervention. Information on design and physical properties like compliance, lubricity, flow system, accuracy, and outcome measures were collected. RESULTS: A total of 23 articles were included. Nine studies described 3D-printed models for stroke intervention. Tango Plus (Stratasys) was the most common material used to develop these models. Four studies described a population-representative geometry model. All other studies reported patient-specific vascular geometry. Eight studies reported complete reconstruction of the circle of Willis, anterior, and posterior circulation. Four studies reported a model with extracranial vasculature. One prototype study reported compliance and lubricity. Reported circulation systems included manual flushing, programmable pistons, peristaltic, and pulsatile pumps. Outcomes included thrombolysis in cerebral infarction, post-thrombectomy flow restoration, surgical performance, and qualitative feedback. CONCLUSION: Variations exist in the material, design, and extent of reconstruction of vasculature of 3D-printed models. There is a need for objective characterization of 3D-printed vascular models. We propose the development of population representative 3D-printed models for skill improvement or device testing.

5.
Acta Neurochir (Wien) ; 162(6): 1353-1362, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32215742

RESUMO

BACKGROUND: There is wide variation in the reported size of ruptured intracranial aneurysms and methods of size estimation. There is widespread belief that small aneurysms < 7 mm do not rupture. Therefore, we performed a systematic review and meta-analysis of the literature to determine the size of ruptured aneurysms according to aneurysm locations and methods of size estimation. METHODS: We searched PubMed, Cochrane, CINAHL, and EMBASE databases using a combination of Medical Subject Headings (MeSH) terms. We included articles that reported mean aneurysm size in consecutive series of ruptured intracranial. We excluded studies limited to a specific aneurysm location or type. The random-effects model was used to calculate overall mean size and location-specific mean size. We performed meta-regression to explain observed heterogeneity and variation in reported size. RESULTS: The systematic review included 36 studies and 12,609 ruptured intracranial aneurysms. Overall mean aneurysm size was 7.0 mm (95% confidence interval [CI 6.2-7.4]). Pooled mean size varied with location. Overall mean size of 2145 ruptured anterior circulation aneurysms was 6.0 mm (95% CI 5.6-6.4, residual I2 = 86%). Overall mean size of 743 ruptured posterior circulation aneurysms was 6.2 mm (95% CI 5.3-7.0, residual I2 = 93%). Meta-regression identified aneurysm location and definition of size (i.e., maximum dimension vs. aneurysm height) as significant determinants of aneurysm size reported in the studies. CONCLUSIONS: The mean size of ruptured aneurysms in most studies was approximately 7 mm. The general wisdom that aneurysms of this size do not rupture is incorrect. Location and size definition were significant determinants of aneurysm size.

6.
World Neurosurg ; 137: e454-e461, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32058116

RESUMO

OBJECTIVE: Despite an increasing focus on endovascular treatment of cerebral aneurysms, microsurgical clipping remains an integral part of management. We evaluated the safety and effectiveness of microsurgical clipping performed by dual-trained neurosurgeons at our institute, which has adopted an endovascular first approach. METHODS: We retrospectively reviewed clinical and radiographic data of 412 aneurysms in 375 patients treated with microsurgical clipping. Univariate and multivariate analyses were performed to identify predictive outcome factors. We defined favorable outcome as a modified Rankin Scale (mRS) score of 0-2 at last clinical follow-up; unfavorable outcome was an mRS score of 3-6. We compared outcomes in our series with those of seminal aneurysm clipping series. RESULTS: Clipping of 330 of 351 unruptured aneurysms (94.01%) was associated with favorable outcome during the follow-up period (mean, 26.5 months). On univariate analysis, older patient age, intraoperative rupture, and higher baseline mRS scores were associated with unfavorable outcome in the unruptured cohort. On multivariate analysis, older age, higher baseline mRS scores, and posterior circulation aneurysm location were predictive of unfavorable outcome. Clipping of 46 of 61 ruptured aneurysms (75.4%) was associated with favorable outcome during the follow-up period (mean, 23.1 months). On univariate analysis, left-sided aneurysms, intraoperative rupture, and large aneurysm size were associated with unfavorable outcome in the ruptured cohort. On multivariate analysis, female sex was predictive of unfavorable outcome. CONCLUSIONS: Our ruptured and unruptured cohort results compared favorably with those in seminal series. Treatment by neurosurgeons adept at both endovascular and microsurgical techniques may improve clinical outcomes.

7.
J Neurointerv Surg ; 2020 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-32046993

RESUMO

BACKGROUND: A new dual resolution imaging x-ray detector system (Canon Medical Systems Corporation, Tochigi, Japan) has a standard resolution 194 µm pixel conventional flat-panel detector (FPD) mode and a high-resolution 76 µm high-definition (Hi-Def) mode in a single unit. The Hi-Def mode enhances the visualization of the intravascular devices. OBJECTIVE: We report the clinical experience and physician evaluation of this new detector system with Hi-Def mode for the treatment of intracranial aneurysms using a Pipeline embolization device (PED). METHODS: During intervention at our institute, under large field of view (FOV) regular resolution FPD mode imaging, the catheter systems and devices were first guided to the proximity of the treatment area. Final placement and deployment of the PED was performed under Hi-Def mode guidance. A post-procedure 9-question physician survey was conducted to qualitatively assess the impact of Hi-Def mode visualization on physicians' intraoperative decision-making. One-sample t-test was performed on the responses from the survey. Dose values reported by the x-ray unit were also recorded. RESULTS: Twenty-five cases were included in our study. The survey results indicated that, for each of the nine questions, the physicians in all cases indicated that the Hi-Def mode improved visualization compared with the FPD mode. For the 25 cases, the mean cumulative entrance air kerma was 2.35 Gy, the mean dose area product (DAP) was 173.71 Gy.cm2, and the mean x-ray exposure time was 39.30 min. CONCLUSIONS: The Hi-Def mode improves visualization of flow diverters and may help in achieving more accurate placement and deployment of devices.

8.
J Neurointerv Surg ; 12(6): 585-590, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31959632

RESUMO

BACKGROUND: A Pipeline embolization device (PED; Medtronic, Dublin, Ireland) can be deployed using either a biaxial or a triaxial catheter delivery system. OBJECTIVE: To compare the use of these two catheter delivery systems for intracranial aneurysm treatment with the PED. METHODS: A retrospective study of patients undergoing PED deployment with biaxial or triaxial catheter systems between 2014 and 2016 was conducted. Experienced neurointerventionalists performed the procedures. Patients who received multiple PEDs or adjunctive coils were excluded. The two groups were compared for PED deployment time, total fluoroscopy time, patient radiation exposure, complications, and cost. RESULTS: Eighty-two patients with 89 intracranial aneurysms were treated with one PED each. In 49 cases, PEDs were deployed using biaxial access; triaxial access was used in 33 cases. Time (min) from guide catheter run to PED deployment was significantly shorter in the biaxial group (24.0±18.7 vs 38.4±31.1, P=0.006) as was fluoroscopy time (28.8±23.0 vs 50.3±27.1, P=0.001). Peak radiation skin exposure (mGy) in the biaxial group was less than in the triaxial group (1243.7±808.2 vs 2074.6±1505.6, P=0.003). No statistically significant differences were observed in transient and permanent complication rates or modified Rankin Scale scores at 30 days. The triaxial access system cost more than the biaxial access system (average $3285 vs $1790, respectively). Occlusion rates at last follow-up (mean 6 months) were similar between the two systems (average 88.1%: biaxial, 89.2%: triaxial). CONCLUSION: Our results indicate near-equivalent safety and effectiveness between biaxial and triaxial approaches. Some reductions in cost and procedure time were noted with the biaxial system.

9.
Curr Neurovasc Res ; 17(1): 58-70, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31987021

RESUMO

BACKGROUND: Endovascular treatment of intracranial aneurysms (IAs) by flow diverter (FD) stents depends on flow modification. Patient-specific modeling of FD deployment and computational fluid dynamics (CFD) could enable a priori endovascular strategy optimization. We developed a fast, simplistic, expansion-free balls-weeping algorithm to model FDs in patientspecific aneurysm geometry. However, since such strong simplification could result in less accurate simulations, we also developed a fast virtual stenting workflow (VSW) that explicitly models stent expansion using pseudo-physical forces. METHODS: To test which of these two fast algorithms more accurately simulates real FDs, we applied them to virtually treat three representative patient-specific IAs. We deployed Pipeline Embolization Device into 3 patient-specific silicone aneurysm phantoms and simulated the treatments using both balls-weeping and VSW algorithms in computational aneurysm models. We then compared the virtually deployed FD stents against experimental results in terms of geometry and post-treatment flow fields. For stent geometry, we evaluated gross configurations and porosity. For post-treatment aneurysmal flow, we compared CFD results against experimental measurements by particle image velocimetry. RESULTS: We found that VSW created more realistic FD deployments than balls-weeping in terms of stent geometry, porosity and pore density. In particular, balls-weeping produced unrealistic FD bulging at the aneurysm neck, and this artifact drastically increased with neck size. Both FD deployment methods resulted in similar flow patterns, but the VSW had less error in flow velocity and inflow rate. CONCLUSION: In conclusion, modeling stent expansion is critical for preventing unrealistic bulging effects and thus should be considered in virtual FD deployment algorithms. Also endowed with its high computational efficiency and superior accuracy, the VSW algorithm is a better candidate for implementation into a bedside clinical tool for FD deployment simulation.

10.
J Neurosurg ; : 1-6, 2020 Jan 24.
Artigo em Inglês | MEDLINE | ID: mdl-31978888

RESUMO

OBJECTIVE: The mortality rates for stroke are decreasing, yet it remains a leading cause of disability and the principal neurological diagnosis in patients discharged to nursing homes. The societal and economic burdens of stroke are substantial, with the total annual health care costs of stroke expected to reach $240.7 billion by 2030. Mechanical thrombectomy has been shown to improve functional outcomes compared to medical therapy alone. Despite an incremental cost of $10,840 compared to medical therapy, the improvement in functional outcomes and decreased disability have contributed to the cost-effectiveness of the procedure. In this study the authors describe a physician-led device bundle purchase program implemented for the delivery of stroke care. METHODS: The authors retrospectively reviewed the clinical and radiographic data and device-associated charges of 45 consecutive patients in whom a virtual "stroke bundle" model was used to purchase mechanical thrombectomy devices. RESULTS: Use of the stroke bundle to purchase mechanical thrombectomy devices resulted in an average savings per case of $2900.93. Compared to the traditional model of charging for devices à la carte, this represented an average savings of 25.2% per case. The total amount of savings for these initial 45 cases was $130,542.00. Thrombolysis in Cerebral Infarction scale grade 2b or 3 recanalization occurred in 38 patients (84.4%) using these devices. CONCLUSIONS: Purchasing devices through a bundled model resulted in substantial cost savings while maintaining the therapeutic efficacy of the procedure, further pushing the already beneficial long-term cost-benefit curve in favor of thrombectomy.

11.
Neurosurgery ; 2020 Jan 24.
Artigo em Inglês | MEDLINE | ID: mdl-31980826

RESUMO

BACKGROUND: There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series. OBJECTIVE: To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms. METHODS: This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up. RESULTS: A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients. CONCLUSION: The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.

13.
J Neurointerv Surg ; 12(3): 260-265, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31444289

RESUMO

INTRODUCTION: Accurate estimation of the incidence of large vessel occlusion (LVO) is critical for planning stroke systems of care and approximating workforce requirements. This systematic review aimed to estimate the prevalence of LVO among patients with acute ischemic stroke (AIS), with emphasis on definitions and methods used by different studies. METHODS: A systematic literature review was performed to search for articles on the prevalence of LVO and AIS. All articles describing the frequency of LVO frequency among AIS patients were included. Studies without consecutive recruitment or confirmation of LVO with CT angiography or MR angiography were excluded. Heterogeneity of the studies was assessed; meta-regression was performed to estimate the effect of LVO definition and study methods on LVO prevalence. RESULTS: 18 articles met the inclusion criteria: 5 studies presented population based estimates; 13 provided single hospital experiences (5 prospective, 8 retrospective). The AIS denominator (number of all AIS) from which LVO rates were generated was variable. Nine different definitions were used, based on occlusion site. Significant heterogeneity existed among the studies (I2=99%, P<0.001). The prevalence of LVO among patients with suspected AIS ranged from 13% to 52%. Overall prevalence was 30.0% (95% CI 25.0% to 35.0%). Pooled prevalence of LVO among suspected AIS patients was 21% (95% CI 19% to 30%). Based on meta-regression, the method of AIS denominator determination significantly influenced heterogeneity (P=0.018). CONCLUSION: The heterogeneity of LVO estimates was remarkably high. The method of AIS denominator determination was the most significant predictor of LVO estimates. Studies with a standardized LVO definition and methods of AIS estimation are necessary to estimate the true prevalence of LVO among patients with AIS.

14.
World Neurosurg ; 133: e434-e442, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31525478

RESUMO

OBJECTIVE: To assess the association of degree of contrast stasis in intracranial aneurysms (IAs) immediately after Pipeline embolization device (PED; Medtronic, Dublin, Ireland) deployment with 6- and 12-month angiographic occlusion rates. METHODS: This retrospective cohort study included consecutive patients undergoing PED deployment for saccular IA treatment at a large-volume cerebrovascular center over a 4-year 9-month period. Angiographic images obtained immediately after PED deployment were graded according to amount of intra-aneurysmal contrast flow during the late venous phase: 0 = no stasis; 1 = <50% contrast stasis; 2 = 50%-75% stasis; and 3 = >75%-99% stasis. Follow-up occlusion rates were determined by digital subtraction angiography, computed tomographic angiography, or magnetic resonance angiography. RESULTS: The study included 119 patients in whom 182 PEDs were deployed to treat 141 aneurysms. A single PED was deployed in 105 (74.5%) aneurysms. The internal carotid artery was the commonest aneurysm site (119 [85%]). Fifty-two (36.9%) aneurysms were grade 0; 33 (23.4%) were grade 1; 46 (32.6%) were grade 2; and 10 (7.1%) were grade 3 immediately post-treatment. A 6-month follow-up angiogram available for 101 aneurysms showed complete occlusion (no flow into the aneurysm) in 74 (73.3%) aneurysms. A 12-month follow-up study available for 132 aneurysms showed complete occlusion in 79.5%. At last follow-up, occlusion rates were not significantly different for different contrast stasis grades (P = 0.60). Mean angiographic follow up for all IAs was 23v±v17.7 months. IA size, sex, age, and smoking were not significant predictors of occlusion. CONCLUSIONS: The degree of aneurysm contrast stasis immediately after PED deployment is not statistically associated with 6- and 12-month angiographic occlusion rates.


Assuntos
Embolização Terapêutica/instrumentação , Hemorreologia , Aneurisma Intracraniano/terapia , Stents , Adulto , Idoso , Angiografia Digital , Angiografia Cerebral , Meios de Contraste/farmacocinética , Embolização Terapêutica/métodos , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Método Simples-Cego , Trombose/etiologia , Resultado do Tratamento
15.
Neurol Clin ; 38(1): 201-214, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31761059

RESUMO

Deep brain stimulation is the most advanced and effective neuromodulation therapy for Parkinson disease, essential tremor, and generalized dystonia. This article discusses how imaging improves surgical techniques and outcomes and widens possibilities in translational neuroscience in Parkinson disease, essential tremor, generalized dystonia, and epilepsy. In movement disorders diffusion tensor imaging allows anatomic segment of cortical areas and different functional subregions within deep-seated targets to understand the side effects of stimulation and gain more data to describe the therapeutic mechanism of action. The introduction of visualization of white matter tracks increases the safety of neurosurgical techniques in functional neurosurgery and neuro-oncology.

16.
Neurosurgery ; 86(Supplement_1): S55-S63, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31838527

RESUMO

Several studies have shown the efficacy and feasibility of flow diversion for the endovascular treatment of wide-necked and otherwise anatomically challenging intracranial aneurysms (IA). Technological advances have led to successful long-term occlusion rates and a safety profile for flow-diverter stents that parallels other endovascular and open surgical options for these lesions. With growing indications for use of the Pipeline Embolization Device (PED, Medtronic, Dublin, Ireland) to include IAs up to the internal carotid artery (ICA) terminus, understanding the nuances of this technology is increasingly relevant. Furthermore, there is a growing body of literature on the use of flow diversion to treat distal (up to A2, M2, and P2), ruptured, and posterior circulation aneurysms, although these applications are "off-label" at present. In this manuscript, we discuss the expanding role of flow diversion in the ICA and compare this technique with other endovascular options for the treatment of ICA IAs. We also discuss technical nuances of the deployment of flow diverters for the treatment of challenging lesions and in difficult and tortuous anatomy.

17.
Artigo em Inglês | MEDLINE | ID: mdl-31748780

RESUMO

BACKGROUND AND IMPORTANCE: Few studies describe the use of adenosine-induced cardiac systole for treatment of cerebrovascular pathologies. We describe a midbrain arteriovenous malformation (AVM) treated with transvenous embolization using adenosine-induced asystole to achieve transient systemic hypotension with the purpose of furthering discussion on the technique and operative considerations for adenosine use in endovascular AVM treatments. CLINICAL PRESENTATION: A 29-yr-old man presented with sudden onset of severe bilateral headache, blurred vision, and numbness on the right side of his face and tongue. Noncontrast head computed tomography revealed fourth ventricle hemorrhage. Diagnostic cerebral angiography revealed a high-flow midbrain AVM with a posterior wall perforator from the basilar artery terminus and a draining vein into the straight sinus. Transarterial AVM embolization was successful. The patient was discharged with no residual neurological deficits but returned 1 wk later with slurred speech and left-sided dysmetria. Repeat angiography revealed partial AVM filling. Attempts at transarterial embolization were unsuccessful. Thus, transvenous AVM embolization with adenosine-induced cardiac asystole and systemic hypotension was performed. A total of 60 mg of adenosine was administered, followed by 2 additional doses of 60 and 40 mg; and complete cardiac asystole with a mean arterial pressure of 40 mmHg was maintained, resulting in successful embolization of the AVM. No residual filling was visualized on postembolization arterial angiography runs. The patient was neurologically stable and discharged on postoperative day 2. CONCLUSION: With appropriate and safe dosing, adenosine-induced asystole and systemic hypotension may be a feasible, safe option to reduce flow and assist endovascular transvenous embolization of high-flow AVMs.

18.
Interv Neuroradiol ; : 1591019919888130, 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31766960

RESUMO

BACKGROUND: Controversy exists regarding the optimum number of flow diverters for the treatment of intracranial aneurysms. We explored the effect of the number of Pipeline embolization devices (PEDs; Medtronic, Dublin, Ireland) deployed on rates of aneurysm occlusion and complications. METHODS: Consecutive patients who underwent saccular intracranial aneurysm treatment solely with the PED were included in this retrospective study. Computed tomographic, magnetic resonance, or digital subtraction angiographic images at 6 and 12 months and last follow-up (>12 months) were reviewed for aneurysm occlusion. Complication and retreatment rates were recorded and analyzed statistically. RESULTS: The study included 141 aneurysm treatments in 119 patients. A single PED was deployed in 105 cases, two PEDs in 31 cases, and three PEDs in 5 cases (total = 182 devices). Six-month angiographic data were available for 103 patients. Occlusion rates were 67.1% for single-PED cases and 90.0% for cases with > 1 PED (p = 0.028). The 12-month occlusion rate (follow-up available for 132) for single-PED cases was 74.7% compared to 91.7% for multiple-PED cases (p = 0.04). On multivariate analysis, number of PEDs was an independent predictor of aneurysm occlusion at 12 months (odds ratio 6.3, 95% confidence interval 1.8-22.8, p = 0.005). Thromboembolic complication rates were the same in the single- and multiple-PED treatment groups (2.8%). The retreatment rate was higher in patients treated with a single PED (16.2% vs. 0%, p = 0.01). CONCLUSIONS: Deployment of > 1 Pipeline embolization device was associated with higher intracranial aneurysm occlusion and lower retreatment rates. No significant difference was found in complication rates.

19.
Artigo em Inglês | MEDLINE | ID: mdl-31504887

RESUMO

Flow diversion using a Pipeline embolization device (PED; Medtronic, Dublin, Ireland) is an effective therapy for treating cavernous aneurysms. Currently, flow diverters require a 0.027-inch microcatheter for deployment. To navigate across these aneurysms, a 0.014-inch microwire is used, which often does not offer a sturdy enough rail to advance a 0.027-inch microcatheter past dissecting artery aneurysm ostia. We present a patient with a right cavernous dissecting carotid artery aneurysm. A step off between the 0.027-inch VIA microcatheter (MicroVention Terumo, Tustin, California) and 0.014-inch Synchro 2 microwire (Stryker Neurovascular, Fremont, California) resulted in difficulty with navigation of the microcatheter across the dissected portion of the aneurysm. A dual microwire rail technique involving two 0.014-inch Synchro 2 microwires was used to advance the VIA microcatheter past the dissecting artery aneurysm ostia for PED deployment. The introduction of the second microwire eliminated the step off between the microwire and microcatheter, providing a stronger rail and easier navigation of the microcatheter, without aggressive pushing. Postembolization runs showed optimal wall apposition and contrast stasis within the aneurysm, with successful flow diversion of the aneurysm. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary.

20.
Neurosurgery ; 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31435656

RESUMO

BACKGROUND: Symptomatic intracranial atherosclerotic disease (ICAD) is an important cause of stroke. Although the high periprocedural risk of intracranial stenting from recent randomized studies has dampened enthusiasm for such interventions, submaximal angioplasty without stenting may represent a safer endovascular treatment option. OBJECTIVE: To examine the periprocedural and long-term risks associated with submaximal angioplasty for ICAD based on the available literature. METHODS: All English language studies of intracranial angioplasty for ICAD were screened. Inclusion criteria were as follows: ≥ 5 patients, intervention with submaximal angioplasty alone, and identifiable periprocedural (30-d) outcomes. Analysis was co-nducted to identify the following: 1) periprocedural risk of any stroke (ischemic or hemorrh-agic) or death, and 2) stroke in the territory of the target vessel and fatal stroke beyond 30 d. Mixed effects logistic regression was used to summarize event rates. Funnel plot and rank correlation tests were employed to detect publication bias. The relative risk of periprocedural events from anterior vs posterior circulation disease intervention was also examined. RESULTS: A total of 9 studies with 408 interventions in 395 patients met inclusion criteria. Six of these studies included 113 posterior circulation interventions. The estimated pooled rate for 30-d stroke or death following submaximal angioplasty was 4.9% (95% CI: 3.2%-7.5%), whereas the estimated pooled rate beyond 30 d was 3.7% (95% CI: 2.2%-6.0%). There was no statistical difference in estimated pooled rate for 30-d stroke or death between patients with anterior (4.8%, 95% CI: 2.8%-7.9%) vs posterior (5.3%, 95% CI: 2.4%-11.3%) circulation disease (P > .99). CONCLUSION: Submaximal angioplasty represents a potentially promising intervention for symptomatic ICAD.

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