Intra-Arterial Therapy for Acute Stroke and the Effect of Technological Advances on Recanalization: Findings in a Community Hospital.

BACKGROUND: Recent randomized controlled studies have shown improvement in recanalization outcomes when physicians use the latest intra-arterial therapy devices in patients with acute, large-vessel, intracranial occlusions. The goal of this study was to explore how new procedures affected degree of and time to recanalization at a single center over the past 12 years as technology has improved. METHODS: Patients were included in the study if they had a large or medium intracranial vessel occlusion and had undergone intra-arterial therapy for acute stroke during the period 2002-2013. Therapies were categorized as intra-arterial thrombolysis with tissue plasminogen activator (IA tPA), mechanical thrombectomy using 1st-generation devices (Merci and Penumbra), or mechanical thrombectomy using 2nd-generation devices (stent-trievers). Recanalization was defined using a modified Thrombolysis in Cerebral Infarction (TICI) scale. RESULTS: Primary treatment was IA tPA in 24 (12.4%) patients, 1st-generation devices in 128 (66.0%) patients, and 2nd-generation devices in 42 (21.6%) patients. TICI 2b was achieved in 7 (29.2%) patients treated with IA tPA, in 79 (61.7%) patients treated with 1st-generation devices, and in 38 (90.5%) patients treated with 2nd-generation devices. Compared to patients treated with IA tPA, patients treated with 2nd-generation devices were more likely to reach TICI 2b recanalization (odds ratio, 11.66; 95% CI, 1.56-87.01), and they did so in shorter times. CONCLUSION: Technological advances over 12 years in endovascular stroke treatments significantly improved the chance of and reduced time to achieving TICI 2b recanalization in our community hospital. This shows the importance of adopting new technologies in a rapidly evolving field in order to provide the best-practice standard of care for the people of our region.

Vertebroplasty in the mid- and upper thoracic spine.

BACKGROUND AND PURPOSE: Vertebroplasty performed in the mid- and upper thoracic spine presents technical challenges that differ from those in the lower thoracic and lumbar region. We herein report results of percutaneous vertebroplasty for treatment of painful, osteoporotic compression fractures in the mid- and upper thoracic spine. METHODS: Retrospective chart review identified vertebroplasty treatments performed for painful osteoporotic compression fractures at T4-T8. The following were catalogued: percentage of vertebral body compression, needle size, surgical approach, clinical outcome, volume of cement injected, and complications. RESULTS: Sixty-three vertebral bodies were treated in 41 patients. Mean percentage of compression was 44%. Bipediculate injections were used in 12 (19%) of 63 treatment levels, and unipediculate injections were used in 51 (81%) of treatments (75 injections performed). Eleven-gauge needles were used for 55 (73%) of the 75 injections, and 13-gauge needles were used for 20 (27%). Clinical follow-up was available for 76% of the patients. Mean pre- and postoperative pain intensity was 9.7 +/- 1.0 and 1.7 +/- 1.9, respectively (P <.0001). Mean pre- and postoperative medication scores were 3.4 +/- 0.7 and 1.7 +/- 1.7, respectively (P =.075). Fracture involving the pedicle used for needle access was noted in one (1.3%) of 75 injections; this pedicle had been traversed using a 13-gauge needle. Staphylococcus epidermidis infection occurred in one case. No cases of pneumothorax were noted. CONCLUSION: Transpedicular vertebroplasty is readily and safely performed using 11-gauge needles in the mid- and upper thoracic regions, yielding excellent pain relief and low complication rates.

The therapeutic benefit of repeat percutaneous vertebroplasty at previously treated vertebral levels.

BACKGROUND AND PURPOSE: Recurrent pain after vertebroplasty is relatively common, usually representing a new fracture at a different vertebral level. In a small cohort described herein, clinical and imaging findings indicated that recurrent pain arose from abnormality of the previously treated level. Our purpose was to demonstrate that repeat percutaneous vertebroplasty performed within the same fractured vertebra can offer therapeutic benefit for patients with recurrent pain after initial treatment. METHODS: We conducted a retrospective review of consecutive vertebroplasty procedures performed at our institution to define a patient population that underwent repeat vertebroplasty for recurrent pain at previously treated vertebral levels. We identified six such patients over an 8-year period, and clinical outcomes were assessed through quantitative measurements of pre- and postoperative levels of pain and mobility. RESULTS: Initial vertebroplasty resulted in substantial improvement in pain in all six patients. Patients developed recurrent pain between 8 days and 167 days after initial vertebroplasty. After repeat vertebroplasty, five of the six patients reported a reduction of at least 3 points in their rating of pain, with a mean reduction of 6.5 points and a mean postoperative pain level of 3.5 points (11-point scale). Four of six patients reported impaired mobility before repeat vertebroplasty, and all four demonstrated a postoperative improvement in mobility. Mean increase in mobility was 1.50 points, and the mean postoperative mobility impairment was 0.25 points (5-point scale). CONCLUSION: The clinical outcomes of the patients within this case series suggest that repeat percutaneous vertebroplasty performed at previously treated vertebral levels for recurrent pain offer therapeutic benefit.

Surgical salvage of microcatheter-induced aneurysm perforation during coil embolization.

We report a case of iatrogenic aneurysm rupture during coil embolization in a 55-year-old woman. Surgical intervention resulted in a good clinical outcome. To our knowledge, this technique for the salvage of catheter-induced aneurysm perforation has not been previously reported.

Radiation dose to the operator during vertebroplasty: prospective comparison of the use of 1-cc syringes versus an injection device.

BACKGROUND AND PURPOSE: Percutaneous vertebroplasty procedures require relatively long durations of fluoroscopic guidance, which might lead to substantial radiation dose to operators. Specialized injection devices have been proposed to limit operator exposure. Our purpose was to compare the radiation dose to the operator's hands during vertebroplasty when using 1-cc syringes versus that when using an injection device. METHODS: Radiation dosimeters were worn on the left wrist during 39 vertebroplasty injection procedures in 25 patients. Cases were alternated between the use of 1-cc syringes (19 procedures) and the use of an injection device (20 procedures). For each procedure, one dosimeter was worn throughout the procedure, both during needle placement and injection, and a second dosimeter was worn during the injection phase only. Mean doses for the whole case and mean doses for the injection procedure alone were compared between groups. RESULTS: Mean whole case dose was 128 +/- 161 mrem (range, 0-660 mrem) for the 1-cc syringe group versus 98 +/- 90 mrem (range, 0-340 mrem) for the injection device group (P =.23). Mean dose during injection was 100 +/- 145 mrem (range, 0-660 mrem) for the 1-cc syringe group versus 55 +/- 43 mrem (range, 0-130 mrem) for the injection device group (P =.09). Three of 19 1-cc syringe cases yielded zero dose, compared with four of 20 injection device cases. Duration of injection was markedly different between groups, with mean injection times of 4.2 and 7.5 min for 1-cc syringe and injection device cases, respectively (P <.00002). Mean injection dose per minute of lateral fluoroscopy was 23.6 and 7.3 mrem for the 1-cc syringe and injection device groups, respectively (P =.002). CONCLUSION: The use of an injection device significantly decreased the radiation dose to the operator's extremity per unit time of injection. However, total dose per injection was equivalent between groups because of significantly longer injection duration for the injection device cohort.

Thrombus formation at the neck of cerebral aneurysms during treatment with Guglielmi detachable coils.

BACKGROUND AND PURPOSE: Thromboembolic events are a common source of complications during Guglielmi detachable coil (GDC) treatment of intracranial aneurysms. Thrombus formation at the coil-parent artery interface is not commonly reported but is an important potential source of emboli. We describe nine cases in which thrombus propagated from GDCs into the parent artery during coil therapy of cerebral aneurysms and subsequent treatment of the thrombus. METHODS: A retrospective review of a procedural database was performed to identify cases in which thrombus occurred during GDC treatment of cerebral aneurysms during a 30-month period. All images were reviewed at the time of the procedure. Nine cases of thrombus forming at the coil-parent artery interface and five cases of distal emboli were identified among 210 cases. All patients underwent anticoagulation with heparin during GDC treatment procedures. RESULTS: Thrombus was identified at the coil-parent artery interface during GDC treatment in nine (4.3%) of 210 cases. In each case, the thrombus was recognized before distal embolic complication occurred and was successfully treated with heparin alone (five patients) or with heparin plus a glycoprotein IIb-IIIa inhibitor (four patients). CONCLUSION: Potential clinical complications can be avoided by early recognition of thrombus at the coil-parent artery interface and by administering appropriate medical therapy.

Cardiovascular effects of polymethylmethacrylate use in percutaneous vertebroplasty.

BACKGROUND AND PURPOSE: Previous investigators have described an association between polymethylmethacrylate (PMMA) use in hip arthroplasty and cardiovascular derangement. Our purpose was to evaluate the effects of PMMA injection on patient vital signs during percutaneous vertebroplasty. METHODS: We retrospectively reviewed patient charts at our institution to gather blood pressure, heart rate, and arterial oxygen saturation data for the following time points: before, during, 5 minutes after, and 10 minutes after PMMA injection during percutaneous vertebroplasty. These data were obtained for 142 injections (78 patients), and preinjection vital signs were compared with vital signs during and after PMMA injection. Multivariable regression modeling was used to ascertain the effects of cardiopulmonary comorbidities on vital signs. RESULTS: Mean arterial blood pressure and heart rate during, 5 minutes after, and 10 minutes after PMMA injection were not significantly different from their respective preprocedure values (P =.19-.92). Values for oxygen saturation during PMMA injection and 5 minutes thereafter were not significantly different from preprocedure values (P =.80 and.89, respectively). Oxygen saturation was significantly lower at 10 minutes after injection than before injection (P =.007), although the mean difference was negligible (0.6%). CONCLUSION: We find no generalized association between PMMA injection during percutaneous vertebroplasty and systemic cardiovascular derangement.

Relevance of antecedent venography in percutaneous vertebroplasty for the treatment of osteoporotic compression fractures.

BACKGROUND AND PURPOSE: Controversy exists regarding the utility of antecedent venography in percutaneous vertebroplasty. Our purpose was to determine whether antecedent venography improves clinical outcomes and/or decreases extravertebral cement extravasation in these procedures. METHODS: We retrospective reviewed outcomes of consecutive percutaneous vertebroplasty procedures performed at our institution to define two populations, each consisting of 24 patients treated at 42 vertebral levels. Group 1 included patients who underwent antecedent venography, and group 2 included patients treated without venography. Clinical outcomes were assessed with quantitative measurements of pain and mobility. Venograms and postprocedural radiographs were interpreted to evaluate the number of vertebrae with extravertebral cement extravasation, degree of extravasation at each level, and correlation between venography and vertebroplasty. RESULTS: Pain improved in 19 of 20 group 1 patients, compared with 21 of 22 group 2 patients; mean postoperative pain levels were 1.3 and 1.8, respectively (P =.50), on a scale of 0 (no pain) to 10 (worst pain). All 11 group 1 patients with impaired preoperative mobility reported postoperative improvement, as did all 12 group 2 patients; mean levels of postoperative impaired mobility for groups 1 and 2 were 0.35 and 0.27, respectively (P =.43). Twenty-two of 42 vertebrae treated in group 1 demonstrated extravasation, compared with 28 of 42 in group 2 (P =.266); amounts of extravasation did not differ. Among 22 levels of extravasation in group 1, venograms in 14 showed correlative extravasation. CONCLUSION: Antecedent venography does not significantly improve the effectiveness or safety of percutaneous vertebroplasty performed by qualified, experienced operators.

Lack of preoperative spinous process tenderness does not affect clinical success of percutaneous vertebroplasty.

PURPOSE: Some operators use the lack of point tenderness over compression fractures to exclude patients from undergoing percutaneous vertebroplasty procedures. The purpose of this study was to determine whether this lack of tenderness portends a poorer clinical outcome after vertebroplasty than is achieved in patients with such tenderness. MATERIALS AND METHODS: The authors conducted a retrospective review of consecutive percutaneous vertebroplasty procedures performed at their institution to define two populations. Group 1 included 90 patients with tenderness to palpation over the spinous process of the fractured vertebra, whereas group 2 included 10 patients without such tenderness. This second group presented with back pain and demonstrated tenderness distant from the fracture (n = 5), tenderness lateral to the fracture (n = 4), or no focal tenderness at all (n = 1). All were treated because of edema seen on magnetic resonance (MR) imaging and/or increased activity on bone scan. Clinical outcomes were assessed by quantitative measurements of pre- and postoperative levels of pain (11-point scale) and mobility (five-point scale). RESULTS: Pain improvement of three points or greater occurred in 77 of the 85 patients (91%) in group 1 who complied with follow-up and nine of nine such patients (100%) in group 2, with mean postoperative pain levels of 1.82 and 0.33 points, respectively (P =.14). Forty of 45 patients (89%) in group 1 with impaired preoperative mobility reported improvement postoperatively, as did two of three such patients (67%) in group 2. Mean levels of postoperative impaired mobility for groups 1 and 2 were 0.27 and 0.67 points, respectively (P =.27). CONCLUSION: Pain on palpation over the fractured vertebra is not a necessary requirement in selecting patients who will benefit from percutaneous vertebroplasty. Other factors, such as MR evidence of edema or increased uptake on bone scan, should be weighed considerably in the decision to treat a patient.

Aneurysm growth, elastinolysis, and attempted doxycycline inhibition of elastase-induced aneurysms in rabbits.

PURPOSE: To establish the relationship between elastin degradation and aneurysm growth in New Zealand white rabbit model aneurysms, and to explore the potential for pharmacologic inhibition of elastinolysis and aneurysm growth with use of the matrix metalloproteinase (MMP) inhibitor doxycycline. MATERIALS AND METHODS: Elastase-induced, saccular aneurysms created in the right common carotid artery in 30 animals randomly divided into controls (n = 16) and doxycycline treated (n = 14) were studied. Aneurysm growth was determined by angiography and aneurysm specimens were collected at 7 and 14 days for histologic and immunohistochemical analysis. RESULTS: Aneurysms were characterized by marked elastin degradation and thickening of the arterial wall media in the absence of inflammatory cell markers. There was no evidence for expression of MMPs in the aneurysm wall at any time point. Aneurysm formation and growth were not prevented by the systemic administration of doxycycline. Mean aneurysm width increased from 3.1 +/- 0.7 mm at 3 days to 3.7 +/- 0.8 mm at 7 days and 4.2 +/- 0.8 mm at 14 days (P =.012 and P =.017, respectively). There was no statistically significant difference in aneurysm size and elastin content at any time point between doxycycline treated and control animals. CONCLUSION: Elastase-induced rabbit aneurysm formation is accompanied by total elastin destruction that was not inhibited by the administration of doxycycline. Aneurysms in this model may be caused by the initial infusion of elastase, rather than by ongoing degradation from endogenous proteases released by inflammatory cells.