Postpartum reversible cerebral vasoconstriction syndrome: review and analysis of the current data.

Postpartum reversible cerebral vasoconstriction syndrome (PPRCVS) is a rare but serious cause of headache that occurs in the early postpartum period. The rarity of this disorder has limited the current literature to single case reports and small, observational case series. The lack of familiarity with PPRCVS may contribute to mismanagement of these unique patients and lead to poor outcomes. To address current gaps in the understanding of PPRCVS, this review and data analysis characterizes the demographics, presentation, clinical course, management and prognosis of PPRCVS and provides a general review of the epidemiology, pathophysiology and diagnosis to assist clinicians who may care for patients with this rare disorder.

Impact of vessel choice on outcomes of polyvinyl alcohol embolization for intractable idiopathic epistaxis.

PURPOSE: To determine the safety and efficacy of internal maxillary artery (IMA) and facial artery polyvinyl alcohol (PVA) embolization for treatment of refractory idiopathic epistaxis. MATERIALS AND METHODS: From 1998-2011, 84 patients were referred for endovascular treatment of intractable idiopathic epistaxis. PVA (range, 180-300 µM) particles were used in all cases. One case required microcoils to prevent nontarget embolization. Medical records were reviewed for early recurrences and complications, which were correlated with the number of vessels receiving embolization using the Mantel-Haenszel χ(2)test for linear association; P<.05 was accepted for significance. RESULTS: Vessels chosen for embolization were unilateral IMA in 8 patients, bilateral IMAs in 35 patients, bilateral IMAs with one facial artery in 32 patients, and bilateral IMAs and bilateral facial arteries in 9 patients. Early (<30 d) rebleeding requiring therapy occurred in nine patients (11%). Minor complications occurred in 22 patients (26%) and included mild facial or jaw pain, facial edema, headache, and transient ischemic attack. There was one major complication that consisted of facial skin sloughing and mild lip ulceration in a patient who had embolization of both IMAs and both facial arteries. A linear association was found when the number of vessels receiving embolization was correlated with both the rates of early recurrence (inversely, P = .04) and minor complications (P = .004). CONCLUSIONS: An initial treatment strategy involving embolization of bilateral IMAs with or without embolization of facial arteries for refractory idiopathic epistaxis is safe and effective. Additional facial artery embolization reduces the risk of early recurrence but increases the risk of minor complications.

Comparison of Enterprise with Neuroform stent-assisted coiling of intracranial aneurysms.

OBJECTIVE: The Enterprise stent is the first closed-cell stent designed to treat wide-necked intracranial aneurysms. Advantages of the design can include improvement in keeping coils within an aneurysm and the ability of the stent to be recaptured. We compared the technical and clinical complications of the Enterprise stent with the open-cell Neuroform stent, its primary alternative. SUBJECTS AND METHODS: Patients undergoing Enterprise and Neuroform stent-assisted aneurysm coiling were enrolled in prospective registries starting in March 2007 and February 2003, respectively. All consecutive patients through December 2011 were included. Deployment success and difficulty, stent movement and misplacement, and procedural complications were compared. RESULTS: Enterprise deployment success was high (108 of 115 attempts, 93.9%) with 102 aneurysms receiving a stent compared with Neuroform (173 of 214 attempts, 80.8%, p = 0.001) with 163 aneurysms. Enterprise was easier to deploy (1.7% vs 15.9% difficult deployment, p < 0.0001). There were no significant differences in the rates of stent movement, misplacement, or symptomatic hemorrhage. Symptomatic thromboembolic events, however, were more frequent with the Enterprise stent (8.7% vs 1.4%, p = 0.0021). The Enterprise stent enabled treatment of 10 additional aneurysms that could not be treated with Neuroform and had a higher rate of immediate aneurysm occlusion (87.3% vs 73.0%, p = 0.0058). CONCLUSION: Enterprise was easier to deploy and enabled treatment of additional aneurysms; however, there were more thromboembolic complications. On the basis of these findings, we prefer to use the Neuroform stent first and rely on the Enterprise stent as an easy-to-deliver backup for stent-assisted coiling.

Outcomes of carotid angioplasty and stenting for radiation-associated stenosis.

BACKGROUND AND PURPOSE: In light of their high surgical risk, carotid angioplasty and stent placement may be preferred in patients with radiation-associated carotid stenosis. The purpose of this study was to determine the procedural complication rate, patency, and clinical outcomes after carotid angioplasty and stent placement in this small group of high-risk patients. METHODS: Sixteen patients (mean age, 65 years; 5 women and 11 men) who received radiation therapy for head and/or neck malignancy subsequently developed carotid stenosis (mean, 84%; range, 70%-99%) in a total of 19 carotid arteries, which were treated with angioplasty and stent placement. The patients were followed for a mean time of 28 months (range, 5-78 months) with periodic Doppler studies, angiography, CT angiography, or clinically. RESULTS: In the total 19 stented carotid arteries, 23 procedures were performed (22 stent placement procedures and one repeat angioplasty). The procedural stroke rate was 1/23 (4%). The procedural transient ischemic attack rate was 0/23 (0%). There was one other observed complication: a puncture site hematoma. The 30-day postprocedure complication rate was 0/23 (0%); no neurologic symptoms were reported. Fifteen of the 19 vessels (79%) developed no new stenosis throughout the follow-up period. Two of 19 (11%) vessels had repeat angioplasty and stent placement; 1/19 (5%) had a repeat angioplasty. One restented vessel has remained patent for 50 months. Another restented vessel required a third stent placement 17 months after the second. Two of 19 (11%) vessels occluded per Doppler examination 14 and 22 months postprocedure. CONCLUSION: Angioplasty and stent placement have low rates of complications and restenosis in the treatment of radiation-associated carotid occlusive disease.

Angioplasty and stenting in carotid dissection with or without associated pseudoaneurysm.

BACKGROUND AND PURPOSE: Carotid angioplasty and stent placement may be the preferred treatment in patients with carotid dissection who have failed medical management. The goal of this study was to determine the procedural feasibility and safety as well as long-term complication rates of carotid angioplasty and stent placement in a consecutive cohort of relatively young, high-surgical-risk patients. PATIENTS AND TECHNIQUES: A series of 26 consecutive patients (mean age, 49 years; 15 men and 11 women) who underwent angioplasty and stent placement for carotid dissection with or without pseudoaneurysm from April 1997 to April 2005 at our institution (9 traumatic, 8 spontaneous, and 9 iatrogenic) was retrospectively reviewed. Twenty-eight stents were used in 29 procedures performed on 27 vessels (20 internal carotid arteries and 7 common carotid arteries). Patients were followed with cerebral angiography, CT, sonography, or clinically for a mean of 14.6 months (range, 5 days to 48.2 months) with 17 of 26 patients having at least 6 months of follow-up. Procedural and long-term complication rates were calculated. RESULTS: Dissection-induced stenosis was reduced from 71 +/- 18% to no significant stenosis in 20 of the 21 patients with measurable stenosis. The procedural transient ischemic attack (TIA) rate was 3 of 29 procedures (10.3%). There were no procedural strokes. One patient required angioplasty of a common femoral artery. One procedure was terminated when an asymptomatic new intimal flap was created before intervention. Two patients had occlusions of the treated vessel noted at 22 days (presented with contralateral stroke) and 3.4 months (asymptomatic). There were 2 unrelated deaths from myocardial infarction at 8 days and 15.2 months. Two patients had recurrent ipsilateral TIA at 2.7 months and 12 months. The 30-day occlusion and death rate was 2 of 29 procedures (6.9%). CONCLUSION: In this series, angioplasty and stent placement were effective in relieving stenosis secondary to carotid dissection with or without pseudoaneurysm and have low rates of ischemic complications.

Procedure complications of carotid angioplasty and stent placement without cerebral protection devices.

OBJECT: The goal in this retrospective study was to examine the procedural complication rate for carotid angioplasty and stent placement performed without cerebral protection devices. METHODS: Between March 1996 and December 2003, 167 carotid angioplasty and/or stent placement procedures were performed without cerebral protection devices in 152 patients (57 women and 95 men whose mean age was 64 years, range 19-92 years). Seven of these patients underwent angioplasty alone. Eighty-nine patients presented with focal neurological symptoms. Indications for surgery included atherosclerosis, radiation-associated stenosis, dissection, pseudoaneurysm, and stretched endovascular coils from aneurysm treatment. In this study, the patients' medical records were reviewed for clinical characteristics, techniques used, and resulting intraprocedural and 30-day complication rates. The intraprocedural stroke rate was four (2.4%) of 167; this included three hemispheric strokes and one retinal embolus. All events occurred in patients who had symptomatic stenosis. The procedural transient ischemic complication rate was six (3.6%) of 167, as was the procedural nonneurological complication rate. During the 30 days postprocedure, one patient had died and three had suffered permanent ischemic events (two cerebral and one ocular). The composite 30-day postprocedural stroke and death rate was eight (5%) of 160. The rate of asymptomatic angiographically confirmed abnormalities was 0.6% (one treated vessel that was occluded but asymptomatic). The 30-day rate of nonneurological complications was 2.5%. A strong association between intraprocedural thromboembolic events (eight cases) and prior ischemic symptoms was found (p = 0.01). CONCLUSIONS: Carotid angioplasty and stent placement without cerebral protection devices is safe, particularly in patients without symptomatic stenosis.

Incidence and mechanisms of stroke after permanent carotid artery occlusion following temporary occlusion testing.

BACKGROUND AND PURPOSE: Patients who require sacrifice of the internal carotid artery (ICA) have a substantial risk of stroke, despite preoperative testing with temporary balloon occlusion (TBO). The purpose of this study is to examine the incidence and mechanisms of stroke after permanent carotid artery occlusion in this population. METHODS: Consecutive patients undergoing TBO testing from March 2002 to December 2011 were identified. The protocol included 30 min of balloon occlusion, continuous intraprocedural neurological assessment, angiographic imaging of collateral flow during the occlusion, and perfusion imaging. Clinical records were reviewed for procedure results, procedural complications, and the incidence and causes of stroke, transient ischemic attack (TIA) and death over 6 months. Strokes were categorized as thromboembolic or hypoperfusion based on available clinical and imaging data. RESULTS: One hundred and fifty carotid occlusion tests were performed during the study period, including 84 women and 66 men. No procedural strokes were recorded. Thirty-seven patients (25%) had permanent occlusion of the tested ICA. Six of the 37 patients had ipsilateral stroke (16.2%) and three experienced TIA (8.1%). Two strokes occurred in the immediate postoperative period (thromboembolic), two strokes occurred within days of ICA occlusion (hypoperfusion), and two strokes occurred at least 30 days from the time of ICA occlusion (thromboembolic). CONCLUSIONS: The rate of ischemic stroke following carotid sacrifice remains high and most strokes are thromboembolic in nature. Our testing protocol did not eliminate the risk of hypoperfusion-related stroke. Delayed venous phase by angiography may be a better indicator of hemodynamic tolerance than perfusion imaging.

Endovascular treatment of 346 middle cerebral artery aneurysms: results of a 16-year single-center experience.

BACKGROUND: The endovascular treatment of middle cerebral artery (MCA) aneurysms has been controversial because of the frequency of complex anatomy and the relative ease of surgical clipping in this location. OBJECTIVE: To present a large single-center experience with the endovascular treatment of MCA aneurysms. METHODS: The neurointerventional database at our institution was reviewed for all endovascular treatments of MCA aneurysms. Demographics, aneurysm characteristics, treatment modality, intraprocedural hemorrhagic and thromboembolic events, 30-day neurological events, and follow-up angiographic studies were recorded. RESULTS: From December 1996 to April 2013, 292 patients underwent endovascular treatment of 346 MCA aneurysms. Of these, 341 (98.6%) were successfully completed. Balloon neck remodeling was used in 230 procedures (66.5%). Ninety-five procedures (27.4%) were for ruptured aneurysms. The rate of intraprocedural hemorrhage was 2.6% (9 of 346). The overall rate of intraprocedural thromboembolic events was 13.6% (47 of 346), significantly more common in patients with acute subarachnoid hemorrhage (27.4%; P < .001). The 30-day major (modified Rankin Scale score > 2) neurological event rate was 2.9% (10 of 346), significantly more common in patients with subarachnoid hemorrhage (8.4%) compared with those without (0.8%; P < .001). The rate of complete or near-complete aneurysm occlusion at was 90.6% ≥ 6 months and 91.8% at ≥ 2 years, with an average of 24 months of follow-up available for 247 procedures. CONCLUSION: Endovascular treatment of MCA aneurysms can be safe and effective. However, it is associated with a high asymptomatic thromboembolic event rate that is more frequent in the setting of acute subarachnoid hemorrhage.

Direct puncture sclerotherapy of a thoracic duct cyst presenting as an enlarging left supraclavicular mass.

A 58-year-old woman presented with a palpable mass at the base of the left neck which she had first noticed 12 years previously, shortly after abdominal surgery. The mass had progressively enlarged, resulting in dysphagia, dyspnea and occasional pain. Imaging showed a septated but otherwise simple cystic mass extending into the mediastinum and containing lymphocytic fluid on aspiration. A diagnosis of the rare entity of a thoracic duct cyst with supraclavicular extension was made. The patient opted for percutaneous sclerotherapy of the lesion, which was performed using glacial acetic acid. This resulted in complete resolution of the mass with one treatment. After exclusion of other causes of cystic left supraclavicular masses including cystic neoplasms and pseudoaneurysms of the carotid or subclavian arteries, direct puncture sclerotherapy can be safe and effective.

Endovascular and Surgical Treatment of Unruptured MCA Aneurysms: Meta-Analysis and Review of the Literature.

Introduction. The best treatment for unruptured middle cerebral artery (MCA) aneurysms is unclear. We perform a meta-analysis of recent publications to evaluate the results of unruptured MCA aneurysms treated with surgical clipping and endovascular coiling. Methods. A PubMed search for articles published between January 2004 and November 2013 was performed. The R statistical software package was used to create a random effects model for each desired incidence rate. Cochran's Q test was used to evaluate possible heterogeneity among the rates observed in each study. Results. A total of 1891 unruptured MCA aneurysms, 1052 clipped and 839 coiled, were included for analysis. The complete occlusion rate at 6-9 months mean follow-up was 95.5% in the clipped group and 67.8% in the coiled group (P < 0.05). The periprocedural thromboembolism rate in the clipping group was 1.8% compared with 10.7% in the aneurysms treated by coiling (P < 0.05). The recanalization rate was 0% for clipping and 14.3% for coiling (P = 0.05). Modified Rankin scores of 0-2 were obtained in 98.9% of clipped patients compared to 95.5% of coiled (NS). Conclusions. This review weakly supports clipping as the preferred treatment of unruptured MCA aneurysms. Clinical outcomes did not differ significantly between the two groups.

Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy.

Dilating HIV vasculopathy can be a cause of ischemic and hemorrhagic stroke in patients with HIV. Although first identified in children, this condition is increasingly being recognized in adults and has a dismal natural history under medical or expectant management. Vessel wall invasion by varicella zoster virus, HIV or Mycobacterium avium intracellulare complex (MAI) has been postulated as a possible etiology. We present a case of an adult patient with HIV and chronic disseminated MAI infection who presented with ischemic stroke and three fusiform cerebral aneurysms that were successfully treated with the pipeline embolization device (PED). Flow diversion may be a viable treatment option for patients presenting with this serious neurovascular condition when aneurysm location precludes parent vessel sacrifice or surgical bypass. In addition, platelet function testing with VerifyNow may be valuable in selecting the appropriate P2Y12 receptor antagonist to be used in order to prevent PED thrombosis, since some of the antiretroviral drugs may inhibit clopidogrel or prasugrel metabolism.

Diagnostic yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage, negative initial CT and catheter angiograms, and a negative 7 day repeat catheter angiogram.

PURPOSE: The yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage (SAH), negative initial CT and catheter angiograms (CT angiography (CTA), DSA), and negative 7 day repeat DSA is not well understood. Our aim was to determine the yield of delayed neurovascular imaging for the detection of causative vascular lesions in this clinical scenario. METHODS: We retrospectively examined the yield of delayed CTA and DSA for the detection of causative vascular lesions in patients presenting to our institution with SAH, negative initial CTA and DSA examinations, and a negative 7 day repeat DSA during a 6.5 year period. Two neuroradiologists evaluated the non-contrast CTs to determine the SAH pattern, and the delayed CTAs and DSAs to assess for the presence of a causative vascular lesion. RESULTS: 39 patients were included: 23 men (59%) and 16 women (41%), mean age 55.5 years (range 33-75). 25 patients had diffuse SAH (64.1%), 12 had perimesencephalic SAH (30.8%), and two had peripheral sulcal SAH (5.1%). The delayed neurovascular examination was CTA in 30 patients (76.9%) and DSA in nine patients (23.1%). Mean time to delayed CTA or DSA was 34.9 days (median 34, range 14-69 days). Delayed CTA demonstrated a causative vascular lesion in two patients (5.1%, one small internal carotid artery aneurysm and one small pontine arteriovenous malformation), both with diffuse SAH (yield 8%). CONCLUSIONS: Delayed neurovascular imaging is valuable in the evaluation of patients with diffuse SAH who have negative initial CTA and DSA examinations and a negative 7 day repeat DSA, demonstrating a causative vascular lesion in 8% of patients.

Onyx is associated with poor venous penetration in the treatment of spinal dural arteriovenous fistulas.

BACKGROUND AND PURPOSE: The use of Onyx has become the mainstream for the treatment of cranial dural arteriovenous fistulas (AVFs) and arteriovenous malformations, but the reported success for type I spinal dural arteriovenous fistulas (sDAVFs) remains limited. We review our experience with Onyx and report its limitations in the treatment of spinal AVFs. MATERIALS AND METHODS: We retrospectively reviewed the Interventional Neuroradiology Procedure database at Washington University for cases of sDAVF embolization. Radiology reports were reviewed for fistula classification, treatment technique, and initial and follow-up results. Angiographic images were reviewed to confirm diagnosis, treatment, and penetration of embolisate into the draining vein. RESULTS: With the use of Onyx, sDAVFs were obliterated in six of seven patients at the time of treatment. Follow-up angiography confirmed sDAVF obliteration in two patients, and recurrence in two cases. Two patients had no follow-up. One patient not cured at the time of treatment was treated surgically. Of the nine total treatments, Onyx successfully crossed the nidus into the draining vein in only four cases. Successful venous embolization was facilitated with positioning of the microcatheter to less than 5 mm from the nidus in three of the four cases. The use of n-butyl cyanoacrylate (NBCA) resulted in venous penetration in eight of 10 cases, and short term follow-up cure in seven of 10 patients. CONCLUSIONS: Our experience with Onyx for type I sDAVF embolization has been tempered by difficulty in achieving venous penetration and, consequently, a high rate of recurrence. For management of these fistulas, we favor NBCA or surgical treatment.

Variability in initial response to standard clopidogrel therapy, delayed conversion to clopidogrel hyper-response, and associated thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms.

BACKGROUND AND PURPOSE: Variability in response to clopidogrel therapy is increasingly being recognized as an important factor in thromboembolic and hemorrhagic complications encountered after neurointerventional procedures. This study aims to determine the variability in response to clopidogrel therapy and associated complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms. METHODS: We recorded baseline patient characteristics, co-administered medications, P2Y12 reaction units (PRU) values with VerifyNow, clopidogrel dosing, and thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms at our institution during a 19 month period. RESULTS: 100 patients were included in the study, 76 women and 24 men, mean age 57.3 years. 15 patients exhibited an initial clopidogrel hypo-response (PRU >240) and 21 patients an initial clopidogrel hyper-response (PRU <60). 36 patients had a follow-up VerifyNow test performed without changes to the standard 75 mg daily clopidogrel dose, which demonstrated that 59% of patients who had initially been within the target 60-240 PRU range exhibited a delayed conversion to clopidogrel hyper-response. In our cohort, a clopidogrel hypo-response was associated with a significantly increased risk of thromboembolic complications in patients undergoing cerebral aneurysm treatment with stent assistance or the pipeline embolization device (60%, p=0.003), while a clopidogrel hyper-response was associated with a significantly increased risk of major hemorrhagic complications in all patients undergoing endovascular treatment of cerebral aneurysms (11%, p=0.016). CONCLUSIONS: We found wide and dynamic variability in response to clopidogrel therapy in patients undergoing endovascular treatment of unruptured cerebral aneurysms, which was significantly associated with thromboembolic and major hemorrhagic complications in our cohort.

Size and anatomic location of ruptured intracranial aneurysms in patients with single and multiple aneurysms: a retrospective study from a single center.

BACKGROUND AND PURPOSE: The difference in the relationship between the size of intracranial aneurysms (IAs) and their risk of rupture in patients with singe IAs versus those with multiple IAs is unclear. We sought to retrospectively analyze the size of ruptured IAs (RIAs) in patients with single and multiple IAs in order to study this relationship further. METHODS: We retrospectively measured the size and location of RIAs in all patients who presented to our institute with an acute subarachnoid hemorrhage between 1 January 2005 and 31 December 2010. The IAs were classified by size into very small IAs or VSAs (≤3 mm), small IAs or SAs (>3 mm but ≤7 mm) and others (>7 mm). RESULTS: 379 patients (281 with a single IA, Group 1 and 98 with multiple IAs, Group 2) with 419 treated RIAs were included in the study. VSAs and SAs constituted the majority of RIAs in both groups (33.5% and 45.2% in Group 1 and 24.6% and 50.7% in Group 2) and the mean size of the RIAs was not different between the two groups. VSAs constituted almost two-thirds of all RIAs in certain locations whereas IAs > 7 mm in size did not constitute more than a third of the RIAs at any of the arterial locations. CONCLUSIONS: The high incidence of VSAs, particularly in certain locations in both patient subgroups, suggests that current diagnostic, prognostic and therapeutic options in the management of IAs should be more tailored towards the management of these difficult-to-treat lesions.

Direct puncture sclerotherapy of a thoracic duct cyst presenting as an enlarging left supraclavicular mass.

A 58-year-old woman presented with a palpable mass at the base of the left neck which she had first noticed 12 years previously, shortly after abdominal surgery. The mass had progressively enlarged, resulting in dysphagia, dyspnea and occasional pain. Imaging showed a septated but otherwise simple cystic mass extending into the mediastinum and containing lymphocytic fluid on aspiration. A diagnosis of the rare entity of a thoracic duct cyst with supraclavicular extension was made. The patient opted for percutaneous sclerotherapy of the lesion, which was performed using glacial acetic acid. This resulted in complete resolution of the mass with one treatment. After exclusion of other causes of cystic left supraclavicular masses including cystic neoplasms and pseudoaneurysms of the carotid or subclavian arteries, direct puncture sclerotherapy can be safe and effective.

Hemorrhagic complications after prasugrel (Effient) therapy for vascular neurointerventional procedures.

INTRODUCTION: Dual antiplatelet therapy (DAPT) with aspirin and a thienopyridine (eg, clopidogrel) prevents stent related thromboembolic events in cardiac patients and is frequently utilized during neurointerventional surgery. However, recent data suggest that many patients exhibit clopidogrel resistance. Prasugrel-a newer thienopyridine-lowers the rate of cardiac stent thromboses in clopidogrel non-responders but a paucity of data exist regarding its safety and efficacy in neurointerventional surgery. METHODS: All patients undergoing neurointerventional surgery by a single interventionalist (CJM) over a 20 month period were retrospectively identified. Charts were reviewed for pre- and post-procedural DAPT regimens, pre-procedural coagulation parameters and procedural complications. RESULTS: 76 patients received pre- and post-procedural DAPT for endovascular treatment of an intracerebral aneurysm, dural arteriovenous fistula or intra/extracranial arterial stenosis. 51 patients underwent 55 total procedures and were treated with aspirin/clopidogrel; 25 patients underwent 31 total procedures and were treated with aspirin/prasugrel. Those patients who received aspirin/prasugrel DAPT were identified pre-procedurally to be clopidogrel non-responders. Both treatment groups had a similar percentage of patients undergoing aneurysm coiling, stent assisted aneurysm coiling, aneurysm Onyx embolization, aneurysm pipeline embolization device treatment, extra/intracranial carotid artery angioplasty and stenting, and dural arteriovenous fistula coil embolization. A total of eight (9.3%) hemorrhagic complications were observed, two (3.6%) in the aspirin/clopidogrel group and six (19.4%) in the aspirin/prasugrel group (p=0.02). No differences were noted in hemorrhage rates for each procedure between treatment groups, nor were there any differences in thrombotic complications between groups. CONCLUSION: Our results suggest that DAPT with aspirin/prasugrel may predispose to a higher risk of hemorrhage during neurointerventional surgery compared with DAPT with aspirin/clopidogrel.

Treatment of basilar tip aneurysms with horizontal PCA to PCA stent-assisted coiling: case series.

BACKGROUND AND OBJECTIVE: Coiling of wide-necked basilar tip aneurysms is technically challenging and is often assisted by the placement of a stent. Stent placement in an anterograde fashion either with a single or Y-stent is typical. However, in some cases the posterior cerebral artery (PCA) angle of origin at the base of the aneurysm precludes anterograde catheterization. A series of patients with wide-necked basilar tip aneurysms treated with a single stent placed via the posterior communicating artery from PCA to PCA is presented. METHODS: A retrospective database review was performed to identify all stent-coiled basilar tip aneurysms. Patients with attempted horizontal P1-P1 stenting via the posterior communicating artery were identified. Procedural imaging, follow-up angiography and clinical notes were reviewed. RESULTS: P1-P1 stenting was attempted in 10 patients and was successful in eight. Angiographic follow-up was available in six patients, all of whom had >90% obliteration at last follow-up. There was one procedure-related subarachnoid hemorrhage that resulted in patient death. There were no cases of significant PCA stenosis on angiographic follow-up. CONCLUSIONS: This stenting technique is an effective way to treat wide-necked basilar tip aneurysms but is limited by the anatomy of the posterior communicating arteries and P1 segments.

Pipeline embolization device and subsequent vessel sacrifice for treatment of a bleeding carotid pseudoaneurysm at the skull base: a case report.

An attempt at parent vessel reconstruction with Pipeline embolization devices to treat a mycotic pseudoaneurysm of the internal carotid artery at the skull base is presented. A 50-year-old woman with malignant otitis externa and bilateral temporal bone osteomyelitis presented with brisk bleeding from her left ear. She had bony dehiscence of the left carotid canal at CT and extravasation from a pseudoaneurysm of the carotid petrous segment at angiography. Carotid tortuosity proximally precluded placing a covered stent. After the lesion stopped bleeding spontaneously and given the presence of bilateral osteomyelitis putting the contralateral carotid at risk, the decision was made to attempt preservation of the parent vessel with flow diversion. However, bleeding recurred after 12 days, necessitating carotid sacrifice. This first reported experience in treating a carotid pseudoaneurysm at the skull base with the Pipeline device shows that transient cessation of bleeding is insufficient for flow diversion to be effective.

Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline Embolization Device.

BACKGROUND: There is wide variability in the reported incidence of perioperative thromboembolic (0-14%) and hemorrhagic (0-11%) complications after Pipeline Embolization Device (PED) procedures for cerebral aneurysm treatment, which could be partly due to differences in patient response to the P2Y12 receptor antagonist administered while the PED endothelializes. This study aims to identify an optimal pre-procedure P2Y12 reaction units (PRU) value range and determine the independent predictors of perioperative thromboembolic and hemorrhagic complications after PED procedures. METHODS: We recorded patient and aneurysm characteristics, P2Y12 receptor antagonist administered, pre-procedure PRU value with VerifyNow, procedural variables and perioperative thromboembolic and hemorrhagic complications up to postoperative day 30 after PED procedures at our institution during an 8-month period. Perioperative complications were considered major if they caused a permanent disabling neurological deficit or death. Multivariate regression analysis was performed to identify independent predictors of perioperative complications in our cohort. RESULTS: Forty-four patients underwent 48 PED procedures at our institution during the study period. There were eight thromboembolic and hemorrhagic perioperative complications in our cohort (16.7%), four of which were major (8.3%). A pre-procedure PRU value of <60 or >240 (p=0.02) and a technically difficult procedure (p=0.04) were independent predictors of all perioperative complications. A pre-procedure PRU value of <60 or >240 (p=0.004) and a history of hypertension (p=0.03) were independent predictors of major perioperative complications. CONCLUSIONS: In our cohort, a pre-procedure PRU value of <60 or >240 was the strongest independent predictor of all and major perioperative thromboembolic and hemorrhagic complications after PED procedures.