bluuebunny/crossref_metadata_2025 huggingface dataset:
O-020 A comparison of infarct volumes in patients with large vessel occlusions based on treatment modality: a retrospective analysis: Abstract O-020 Figure 1
Authors: Rangaraju S , Owada K , Noorian A , Glenn B , Belagaje S , Anderson A , Nahab F , Frankel M , Nogueira R , Gupta R
Published: July 2012

Introduction

Intra-arterial (IA) therapy for large vessel occlusions (LVO) results in higher recanalization rates compared to intravenous (IV) thrombolysis. Recanalization after LVO is also a predictor of better clinical outcome. Whether IA therapy results in lower stroke infarct burden has not previously been determined. Infarct volume has been shown to have a strong correlation to 90-day clinical outcome. We hypothesized that patients treated with IA therapy will have lower post-procedure infarct volumes compared to IV thrombolysis or untreated patients.

Materials and methods

A retrospective chart review was performed on consecutive patients with LVO between November 2010 and December 2011 at Emory University Hospital and Grady Memorial Hospital. LVO was defined as extracranial/intracranial internal carotid artery (ICA), M1 middle cerebral artery (MCA) or M2 MCA occlusions identified by CT, MR or conventional angiography. Adults (>18 years) with LVO who presented within 8 h from time last seen normal were included and grouped as follows: those receiving intra-arterial/endovascular therapy(IA group), intravenous thrombolysis only(IV group)and no thrombolysis(Untreated group). Baseline characteristics were recorded on all patients. Infarct volume was measured using subsequent CT or MRI imaging after the first 24 h and compared using the Mann–Whitney U test. Data are represented as box plots showing the median infarct volume and the first and third IQRs for each group (Abstract O-020 figure 1A,B).

Abstract O-020 Figure 1

(A) Infarct Volumes in LVO. (B) Infarct volume based on location of occlusion and treatment modality.

Results

192 patients with LVO met inclusion criteria (IA: 127 patients, IV: 35 patients, Untreated: 30 patients).The mean age for the entire cohort was 66±16 years and the mean NIHSS was 19±6. Baseline clinical characteristics were comparable between the three groups. In all LVOs, median infarct volume was significantly smaller in the IA group compared to the untreated group (Abstract O-020 figure 1A, p=0.02) while infarct volume in the untreated and IV groups was similar (p=0.8). Based on level of occlusion, infarct volume was significantly smaller in the IA group compared to the untreated/IV group (Abstract O-020 figure 1B) in patients with terminal ICA (ICA-T) (p=0.005) and M1 MCA occlusions (p=0.02). Infarct volume in M2 occlusions was similar between the groups (p=0.3).

Conclusions

Endovascular therapy for anterior circulation LVO appears to reduce infarct volumes in patients presenting within 8 h from symptom onset especially in ICA-T and M1 occlusions but not M2 occlusions. Prospective studies are needed to replicate these findings and correlate with clinical outcomes.

Competing interests

None.
P-020 Patterns of aneurysm recurrence following microsurgical clip obliteration: Abstract P-020 Figure 1
Authors: Spiotta A , Schuette A , Moskowitz S , Hui F
Published: July 2012

Introduction

Microsurgical clip obliteration remains a time-honored and viable option for the treatment of select aneurysms with very low rates of recurrence. We studied clipped aneurysms that were found to have recurrences to better understand the patterns and configuration of these rare entities.

Methods

A retrospective review was performed of two prospectively maintained databases of aneurysm treatments from two institutions (Cleveland Clinic and Emory University) that spanned 14 years to identify patients with recurrent previously clipped intracranial aneurysms.

Results

Twenty-six aneurysm recurrences that were previously treated with clipping were identified. Three types of recurrence were identified; Type I proximal to the clip tines, Type II distal, and Type III lateral. The most common type of recurrence was that arising distal to the clip tines (46.1%) and the least frequency encountered recurrence was that arising proximal to the tines (19.2%) Laterally located recurrences were found in 34.6% of cases.

Conclusion

We have described three different patterns of aneurysm recurrence with respect to the clip application and have identified three types; those occurring proximal, distal or lateral to the clip tines. However, it is not possible to discern which of these represent true aneurysm recurrences as opposed to incomplete initial treatments and subsequent enlargement of a residual. Further study of aneurysm recurrences would have to be performed in a prospective manner with closer scrutiny of microsurgically clipped aneurysms.

Competing interests

A Spiotta: Integra Neurosciences, Hemedex. A Schuette: None. S Moskowitz: None. F Hui: None.

Abstract P-020 Figure 1
P-022 Endovascular revascularization of carotid artery using a flow reversal device
Authors: Buciuc R , Luzardo G , Uschmann H
Published: July 2012

Introduction

Surgical carotid revascularization has been described with various degrees of technical and clinical success. Currently, carotid revascularization is not recommended, based on the high potential for embolic stroke during the procedure. The data is however limited to only surgical cases. One series of endovascular revascularization for occluded carotids of unknown length of time has already been communicated. The authors present a similar series using a flow reversal device.

Method

During the period of February 2009 to November 2011 a total of 13 patients underwent endovascular revascularization of either single or both occluded carotid arteries. The procedure was done in all cases using a flow reversal system (the Gore flow reversal) In three cases the procedure had to be aborted due to the fact that the occluded segment included part of the supraclinoid carotid. In the rest of cases the procedure was technically feasible succesfully. After revascularization all patients underwent stenting of their extracranial carotids. Two patients had either bilateral occlusions or presented with a non-disabling stroke due to a severe stenosis on one side and a chronic occlusion on the other. In these cases the revascularizations have been performed in stages with a 2–3 month interval in between interventions.

Results

There were no neurologic complications related to the procedure either in the successful or in the aborted cases. Two patients developed large inguinal hematomas and had to be transfused.

Conclusion

The endovascular revascularization of carotid artery occlusion of unknown duration is feasible using a flow reversal device. Addditional information regarding clinical and imaging indications for the procedure is necessary in order to proper select patients that might benefit. Long term follow-up will also be necessary in order to assess the viability of re-opened carotids as well as risks for stroke in patients after this procedure.

Competing interests

None.
P-023 3D venography in neurointerventional applications
Authors: Buciuc R
Published: July 2012

Introduction

3D venography has been reported previously as an indirect imaging method for visualization of various intracranial venous structures (ex.cavernous sinus). The potential disadvantage of indirect venography is the quality of imaging information which can have large variations and the need for an additional intervention should that be necessary. We present a direct transvenous modality of imaging intra- and extra-cranial venous structures.

Method

A total of three patients have undergone direct 3D venography. Two of the patients had a venography for evaluation of cavernous venous structures and one patient was evaluated for a facial venous malformation. All patients underwent a direct injection of contrast within the structures to be imaged by a transvenous approach. A rotational venogram was performed and the raw data was postprocessed into 3D images. These were further analyzed. In two cases a transvenous intervention followed guided by the information obtained by direct 3D venography.

Results

All patients underwent the study succesfully and without complications. In all cases the venography was essential in either guiding the following intervention or predicting the likelihood of venous bleeding intra-operativelly.

Conclusions

3D venography is a feasible technique with minimal added risks. The study can serve either as a guidance for further trans-venous interventions or as a predictor of intraoparative venous bleeding for trans-sphenoidal surgery.

Competing interests

None.
P-003 Baseline DWI volume predicts successful recanalization in multimodal endovascular therapy for acute ischemic stroke
Authors: Raychev R , Liebeskind D , Saver J , Hao Q , Vinuela F , Tateshima S , Jahan R , Gonzalez N , Szeder V , Cramer R , Balugde A , Rastogi S , Salamon N , Duckwiler G
Published: July 2012

Background

Effective reperfusion is associated with better outcome from acute cerebral ischemia. The pre-intervention clinical and imaging predictors of procedural success in patients treated with multimodal mechanical device strategies (Merci ± Penumbra ± angioplasty and stenting) have not been well delineated.

Methods

In a prospectively maintained database, we analyzed consecutive patients with acute ICA and M1 occlusions treated with endovascular recanalization following MRI. We investigated the pretreatment clinical and imaging factors associated with substantial recanalization (TICI≥2b) and clinical outcome.

Results

Among 105 patients meeting study entry criteria, mean age was 66.6 (±17.8). 65 % were female, median pretreatment NIHSS was 18 (range 2–31), mean baseline DWI volume was 30.6 cc (SD±35.1), and mean time to groin puncture was 412 min (SD±207.6). The median number of mechanical device passes was two (range 0–8). 73 (70%) patients were treated with a single device. IV tPA was used in 43 patients (41%). Substantial recanalization occurred in 43 patients (41%). The strongest predictors of poor outcome (mRS >3 at discharge) were high baseline NIHSS (OR 0.87; p<0.001) and presence of SAH after the procedure (OR 0.05; p=0.001). However, the presence of SAH did not correlate with the number of attempts or devices used. The strongest predictor of better outcome at discharge (mRS ≤3) was substantial recanalization (TICI≥2b). Time to groin puncture, number of device passes, single vs multiple device therapy, adjunctive IV TPA, or arterial occlusion site did not correlate substantial recanalization. In the final logistic regression multivariate analysis, among all baseline clinical and imaging variables considered, the pre-treatment DWI volume was the only factor associated with a substantial recanalization (OR 0.238; p=0.046).

Conclusions

Baseline DWI lesion volume is a potent predictor of substantial reperfusion in multimodal endovascular therapy for acute ischemic stroke. This finding suggests that the effectiveness of the reperfusion therapy is likely influenced by much more complex pathophysiological mechanism, rather than mechanical and/or anatomical factors alone.

Competing interests

None.
P-035 Effect of pre-operative embolization on AVM blood flow
Authors: Alaraj A , Aletich V , Ivanov A , Carlson A , Oh G , Charbel F , Amin-Hanjani S
Published: July 2012

Introduction

Both surgical resection and endovascular embolization are important tools in the treatment of arteriovenous malformations (AVMs). Prior to surgical resection of AVMs, pre-operative embolization is often selectively employed for large or high-flow AVMs, to reduce risk of intra-operative hemorrhage and mitigate the potential for bleeding related to “normal perfusion breakthrough” in the peri-operative period. A primary goal of the embolization is to sequentially and gradually reduce flow in the AVM; the success in achieving this goal is primarily determined through subjective and qualitative assessment of the angiographic runs pre and post embolization. We sought to directly measure the effects of embolization on AVM flow using Quantitative Magnetic Resonance Angiography (QMRA).

Methods

Medical charts, cerebral angiograms, and flow measurements were reviewed in patients with QMRA measurements of AVM flow pre and post embolization. Total AVM flow was calculated based on the aggregate flow within the primary arterial feeders, or flow measured from single draining veins. AVM flows were compared pre and post embolization. All sessions of embolization were performed with N-BCA glue except three sessions where Onyx was used.

Results

51 AVM patients were evaluated with QMRA. Among those, 17 patients had flow measurements pre and post embolization. A total of 42 sessions of embolization were performed (range 1–6 per patient). Average AVM flow prior to treatment was 439 cc/min, ranging from 129 to 952 cc/min in AVMs from 2.3–32 cc in size (median 6.4 cc). The median number of pedicles embolized per session was 3 (range 1–5). Flow dropped by a mean of 133 cc/min (range 14–410 cc/min) per each session of embolization, representing an average 40% flow decline per session relative to flows immediately prior to the embolization. In larger AVMs, overall flow changes were sometimes not evident until the second or third sessions of embolization, suggesting re-channeling of flow through remaining compartments of the nidus. As compared to the baseline, there was an overall 67% (range 27%–99%) reduction in AVM flow at the end of multiple sessions of embolization, with mean AVM flow dropping to 103 cc/min (range 5–300 cc/min) before the surgery. Interestingly, the number of pedicles embolized per session did not correlate with the flow drop, which also correlated poorly with subjective determinations of the extent of embolization at time of angiography.

Conclusion

Flow alterations induced by embolization can be quantified, and may provide a more robust strategy to determine the number and efficacy of preoperative embolization sessions.

Competing interests

A Alaraj: ev3, Cordis-Codman. V Aletich: Micrus. ev3, Cordis-Codman. A Ivanov: None. A Carlson: None. G Oh: None. F Charbel: VasSol Inc. S Amin-Hanjani: None.
P-042 Combined intra-arterial thrombolysis and mechanical thrombectomy versus mechanical thrombectomy endovascular outcomes in acute ischemic stroke: Abstract P-042 Table 1
Authors: Sehgal S , Sharma J , Kulhari A , Shams T , Vargas E , Moradzadeh N , Jung R , Blackham K
Published: July 2012

Background

Endovascular intervention is an important treatment option for patients with acute ischemic stroke who are ineligible for intravenous thrombolysis or fail to respond to such therapy. Endovascular treatments include intra-arterial thrombolysis (IAT) and mechanical thrombectomy (MT). Limited data exists regarding the safety and efficacy of a combination approach using IAT and MT.

Objectives

To assess the safety and efficacy of combined mechanical and IAT therapy compared to MT alone.

Methods

Retrospective chart review was performed in 200 consecutive patients who underwent endovascular treatments for acute ischemic stroke at our center between 2007 and 2011. 115 patients met inclusion criteria of MT alone versus combined MT and IAT. We compared outcome parameters between these two groups including discharge NIHSS, modified Rankin Score (mRS), rate of partial to complete recanalization (TIMI 2–3), symptomatic intracerebral hemorrhage, and all cause mortality.

Results

A total of 115 patients underwent MT alone or received combined therapy. In the MT only group, mean age was 69±13.32 and median initial NIHSS was 17. Of the combined therapy group, 66±16 was the mean age and median initial NIHSS was 18.

Conclusions

In our experience combination MT and IAT in the treatment of acute ischemic stroke had a trend toward higher recanalization rates and number of patients with clinical improvement, as well as, lower discharge NIHSS and higher percentage of independently ambulating patients discharged as compared to MT alone. Despite higher hemorrhage and slightly increased mortality rates, the combined therapy group trended toward better clinical outcomes.

Competing interests

None.

Abstract P-042 Table 1

Primary outcomes between MT only and combined therapy groups

OutcomeMechanical thrombectomy only (N=40)Combined MT and IAT (N=75)Discharge NIHSS129Clinical improvement (NIHSS >4)19 (47.5%)37 (55.2%)TIMI 2–325 (62.5%)57 (76.0%)Discharge mRS ≤33 (7.5%)10 (13.3%)Symptomatic ICH3 (7.5%)13 (17.0%)Mortality8 (20%)20 (26.7%)
E-017 Impact of integrated cerebrovascular program on outcomes in patients with intracranial aneurysms
Authors: Krishna V , Turner R , Chaudry I , Turk A
Published: July 2012

Introduction

Recent evidence indicates that multidisciplinary care improves patient outcomes for cerebrovascular (CV) disease. A multidisciplinary, integrated CV program was recently instituted at a high volume tertiary referral center, providing the opportunity to evaluate patient outcomes before and after its introduction.

Methodology

A retrospective chart review was performed on all new patient encounters for a 6-month time period each before and immediately after the introduction of the CV program, as well as at a more recent 6 month time period to evaluate long-term results. Data were collected on demographic variables, rupture status, medical comorbidities, hospital complications, in-hospital procedures, hospital course, and modified Rankin score at discharge and follow-up.

Results

The total number of patients treated increased from 55 in the 6-month time period before the introduction of CV program to 112 in the most recent time period (p<0.05). Both the number of surgical clipping and endovascular coiling procedures increased (p<0.05). An increase in severity of illness was observed, with a significant increase in patients with multiple comorbidities (30.5% vs 34.7%, p=0.035). Mean length of hospital stay decreased from 12.22±13.26 days before the program to 9.23±12.04 days in the most current data, mainly due to a statistically significant decrease in intensive care unit length of stay between those time periods (p<0.05). Additionally, fewer systemic complications were observed in the most recent time period as compared to before the introduction of CV program.

Conclusions

Creation of an integrated CV program at a large volume tertiary referral center resulted in better outcomes for an increased number of more medically complicated patients with intracranial aneurysms. This study provides preliminary data supporting the development of an integrated model of multidisciplinary care for the management of CV disease.

Competing interests

None.
E-026 An analysis of the anterior circulation cerebrovascular geometry. Baseline measurements of vessel diameter, length and taper
Authors: Rai A , Cline B , Hogg J
Published: July 2012

Background

Endovascular interventions typically require placement of a device in the cerebral vasculature. Knowledge of the cerebrovascular geometry can aid in designing conformable devices. The study's objective was to establish baseline measurements of the anterior circulation in the cerebral vasculature including diameter, length and vessel taper.

Materials and Methods

The sample size was determined for four cohorts based on gender and side; males-right, males-left, females-right and females-left. We reviewed similar measurements in the literature and conservatively chose a SD of 0.5 mm. Using a margin of error of 0.2 and a 95% CI yields a sample size of 25 patients for each sub-group for a total of 100 patients. The sample was calculated from a patient population that had undergone an intracranial CT angiogram. The age cut-off was set at 40 years based on our experience that most patients undergoing neurovascular interventions are above this age group. Patients with any vascular abnormality on the CTA were excluded. Thus 50 consecutive male and female patients were included. The vessel diameter was measured at the proximal cavernous ICA, the ICA terminus, the MCA origin and an M2 origin. The vessel length between these endpoints was calculated along the centerline. The vessel taper was calculated as the change in caliber per mm of length.

Results

The mean length of the ICA from the proximal cavernous segment to the ICA terminus was 33.1±6.1 mm. The mean diameter at the proximal cavernous ICA and the ICA terminus was 5±0.6 mm and 3.6±0.4 mm respectively. The mean ICA taper was 0.04±0.02/mm. For the MCA, the diameter at the M1 and M2 origins measured 3.1±0.4 mm and 2.4±0.4 mm respectively. The mean MCA length was 22.5±8.1 mm. There was no significant difference between male and female patients and between right and left sides. Patients who were older than 60-years had longer ICAs (p=0.02), larger ICA-cavernous (0.003), ICA-terminus (<0.0001) and MCA origin (p=0.01) diameter than those younger than 60-years.

Conclusion

We demonstrate the baseline dimensions of the anterior cerebrovascular circulation. Calculation of the vessel taper has not been done before and is important as an increasing number of endo-luminal devices are becoming available. Knowledge of the vessel taper can allow for development of more conformable devices thus enhancing their effectiveness. We are currently analyzing similar data for the posterior circulation and if accepted intend to present that along with the anterior circulation.

Competing interests

A Rai: Stryker Neurovascular. B Cline: None. J Hogg: None.
E-033 Bow Hunter's syndrome: an unusual cause of symptomatic vertebral artery stenosis
Authors: Miller D , Tawk R , Barrett K
Published: July 2012

Introduction/purpose

Bow Hunter's syndrome is an unusual symptomatic vertebral artery syndrome resulting from intermittent mechanical compression of the vertebral artery. We describe a case of symptomatic left vertebral artery compression diagnosed by dynamic cerebral angiography and discuss the pathophysiology, diagnosis, and treatment of this unusual syndrome.

Materials/methods

A 44-year-old right-handed male was transferred to Mayo Clinic hospital after being admitted to an outside hospital with left-sided weakness and numbness and difficulty with balance. The patient became symptomatic while driving his truck on the highway about 10 days before. An outside MRI confirmed an acute CVA involving the cerebellum and left medulla. An MR angiogram suggested stenosis of the left vertebral artery in the mid cervical region. Cerebral angiography revealed only mild stenosis of the left vertebral artery in the neutral position. Angiograms with the patient had turned to the left revealed almost complete occlusion of the left vertebral artery. Turning the head to the right essentially completely resolved the stenosis. CT angiography with three-dimensional reconstruction confirmed a large uncovertebral spur encroaching on the foramen transversarium at C5-6.

Results

The patient was evaluated for endovascular therapy verses open surgical treatment. He was treated with anterior cervical discectomy and fusion with surgical excision of the spur. This resulted in complete resolution of his symptoms.

Conclusions

Bow Hunter's syndrome is an unusual mechanical entrapment syndrome of the vertebral artery which can be difficult to diagnose with conventional non-invasive imaging. Dynamic cerebral angiography can lead to an appropriate diagnosis. Treatment can be surgical or endovascular, and can lead to complete resolution of symptoms.

Competing interests

None.
E-005 Accuracy of software for intracranial aneurysm geometry quantification: Abstract E-005 Figure 1
Authors: Murayama Y , Mohamed A , Takao H , Ishibashi T , Yuki I
Published: July 2012

Introduction/purpose

Endovascular treatment planning for intracranial aneurysms requires accurate quantification of aneurysm geometry. Today, aneurysm geometry is typically measured manually on an angiographic workstation based on three-dimensional (3D) Digital Subtraction Angiography (DSA) images. Since accuracy and reproducibility of manual measurements are user dependent, computer-aided approaches have been recently proposed. We evaluated prototype software for intracranial aneurysm geometry quantification and compared generated measurements to manual measurements from two experienced raters.

Materials and Methods

We examined 25 saccular unruputured single intracranial aneurysms (sidewall = 17, bifurcation = 8) treated via endovascular coiling at our institution between August 3, 2011 and February 23, 2012. Based on 3D DSA images, Manual measurements of the neck length (N), dome height (H), dome diameter (D) were obtained by two independent experienced raters. The aneurysm volume (V) was computed manually via an image punching and voxel counting approach. Subsequently, prototype cranial aneurysm analysis software (Siemens AG, Forchheim, Germany) was applied to the 3D DSA images to measure the same quantities. The software requires the user to manually mark the aneurysm dome via one point click and the parent artery via two point clicks, proximal and distal to the aneurysm.

Results

The software to average rater errors were compared to inter-rater variability. No statistically significant differences were found between the two error distributions for N, H, D (p=0.371, p=0.567 and p=0.195, respectively). The average software-to-rater errors were N=0.55±1.03 mm, H=0.49±0.58 mm and D=0.45±0.39 mm. The largest errors in N (4.23 mm) and H (2.42 mm) occurred in cases where the 3D image could not adequately separate the aneurysm dome from the parent vessel. For V, data from only one rater were available. The average relative error was 7.76%±6.68% with maximum of 20.9%.

Conclusions

Results indicate good agreement between measurements obtained by the software and two independent manual sets of measurements. In cases where 3D imaging did not adequately separate the aneurysm dome from the neighboring blood vessels, the aneurysm neck length, dome height, and volume measurement errors were the largest. Manual corrections may be necessary in such cases. Further studies on a larger dataset of various aneurysm geometries are needed.

Competing interests

Y Murayama: Siemens AG. A Mohamed: Siemens AG. H Takao: None. T Ishibashi: None. I Yuki: None.

Abstract E-005 Figure 1
E-061 Correlation between CT perfusion (CTP) and MRI in the setting of acute stroke
Authors: Ghobrial G , Chalouhi N , Zohra M , Dalyai R , Tjoumakaris S , Jabbour P , Dumont A , Rosenwasser R , Gonzalez L
Published: July 2012

Introduction

Diffusion weighted imaging (DWI) has its limitations, as evidenced in the literature by reports of variable sensitivity and accuracy. Increasingly, reports of the utility of CT perfusion (CTP) are being made in predicting acceptable thrombolysis candidates. This is being done by evaluating infarct core and discriminating ischemic territory from penumbra in the acute setting.

Methods

A single institution, retrospective review of 21 patients who underwent multimodal endovascular intervention for stroke from January 2010 to 2011 was conducted after institutional review board approval. Immediate CTP of the head and neck was obtained in all cases upon admission. Posterior circulation stroke, lacunar infarcts, and those unable to undergo MRI post-operatively were excluded. Calculated volumes of the penumbra from CTP data were compared to post-operative MRI volumetric calculations of the completed infarct. This data was contrasted to 21 control patients that were excluded from intervention, but had CTP and MRI in the acute setting.

Results

Eleven patients in the interventional group and 10 patients in the control group received intravenous tissue plasminogen activator. In both the control group and interventional groups, DWI studies obtained after multimodal recanalization in all patients demonstrated diffusion restriction in the infarct core. Varying volumes of diffusion restriction were seen in the penumbra. The mean difference calculated between the mismatch area on CTP and the correlating diffusion restriction on MRI was a decrease of 43.01 cm3(p<0.05). In the interventional group, the area of restriction was less than the predicted mismatch area calculated. In the control group, 7 of the 21 patients (33%) had a net increase in the stroke territory. The calculated mean difference between the mismatch on CTP and the diffusion restriction on MRI was a decrease of 14.12 cm3(p<0.05).

Conclusions

DWI and CTP are useful tools in the assessment of ischemic stroke patients in the acute interventional setting. By comparing mismatch on CTP to MRI diffusion restriction after endovascular intervention, we show a decreased conversion of penumbra to stroke than in the patients undergoing medical management alone. Larger, prospective studies with quantitative metrics are necessary for further evaluation of stroke patients.

Competing interests

None.
E-062 Stent-assisted embolization of 71 anterior cerebral artery aneurysms
Authors: Johnson A , Munich S , Heiferman D , Lopes D
Published: July 2012

Introduction

Anterior cerebral artery aneurysms (ACAAs) comprised over half of the ruptured aneurysms in the International Subarachnoid Trial. These lesions tend to rupture at a smaller size than those at other locations. Endovascular treatment of ACAAs has provided excellent results, but until the introduction of intracranial stents, many ACAAs could not be treated without craniotomy. The current study analyzes the results of ACAA treatment using stent-assisted embolization.

Materials and Methods

After being offered the options of observation, endovascular repair, and microsurgical treatment, 69 patients with 71 ACAAs underwent stent-assisted aneurysm repair. Three aneurysms were distal ACAAs. Eight were 10 mm or more in greatest diameter, and all aneurysms were <15 mm. Follow-up angiography was performed 6 months after treatment; then patients were followed with annual magnetic resonance angiography. Immediate, mid-term, and long-term radiographic results and complications were analyzed.

Results

After stent-assisted embolization, 33 (46.5%) ACAAs were completely occluded, 18 had residual neck, and 20 had residual filling. At first radiographic follow-up, 39 of 58 (67.2%) showed complete occlusion. Four aneurysms required retreatment, one with another stenting procedure. After stable initial follow-up angiography, no aneurysms worsened clinically or radiographically during the follow-up period. One patient treated with a three-stent construct died of periprocedural hemorrhage. One major stroke occurred during a hip surgery while the patient discontinued anti-platelet medications. These cases were the only aneurysm-related major morbidity (1.4%) and mortality (1.4%) during the follow-up period.

Conclusion

Stent-assisted aneurysm treatment was a safe and effective option in this series of ACAAs with complex anatomy. Contrary to prevailing opinions regarding the durability of microsurgical and endovascular repair, aneurysms in the anterior cerebral artery distribution may be more likely to recur after clipping, and stent-assisted embolization may be durable after stable initial follow-up.

Competing interests

A Johnson: None. S Munich: None. D Heiferman: None. D Lopes: Stryker, ev3, Penumbra.
E-072 Wake up symptomatic stroke in acute brain ischemia (WASSABI) clinical trial
Authors: Kass-Hout T , Kass-Hout O , Mokin M , Al Masry M , Nourollahzadeh E , Siddiqui A , Levy E , Synder K
Published: July 2012

Background

Stroke is the fourth leading cause of mortality and a major cause of long-term disability in the USA. IV tPA remains the only FDA-approved treatment for AIS. However, it is only approved when the time of onset is known to be <3 h. Approximately 25% of ischemic stroke patients awaken with stroke symptoms. This is called a Wake Up Stroke (WUS). The purpose of this study is to determine if WUS patients with a proof of salvageable penumbra on CT perfusion (CTP) will benefit from IV thrombolysis therapy or endovascular intervention.

Methods

This study is a single center, randomized, single-blinded and prospective study to compare between medical therapy and interventions in patients with WUS. Ninety patients with wake up ischemic stroke and considerable salvageable tissue on perfusion studies (defined as TTP >8 s and volume loss <20% of the size of the penumbra) will be randomized into one of three prospective groups: (1) Best medical therapy (standard of care with anti-platelets and statins), (2) Intravenous thrombolysis (total dose of 0.9 mg/kg) and (3) Intra-arterial intervention (IA t-PA and/or MERCI device and/or PENUMBRA device). The Choice of appropriate endovascular therapy will be decided by an experienced endovascular surgeon.

Statistical analysis

This is an ongoing study. Efficacy end points will be assessed in the intention-to-treat analysis. The primary end point; modified Rankin Scale at 90 days (mRs-90 days) ≤2, will be compared among the different subgroups denoted previously by χ2distribution analysis using the SAS program (SAS V.9.1 Institute INC.). A comparison of NIHSS means among the three groups would also be performed at 24 h post ER presentation and at discharge. Initially One-Way Analysis of Variance (ANOVA) will be carried out. If the ANOVA analysis provides us with statistically significant results suggesting significant difference among the three arms, then Binary comparisons among the groups using Tukey multiple means comparison procedure will be performed. Using the means will be justified in our study since we aim to have a sample size of 90 subjects. Symptomatic intracranial hemorrhage will also be compared among the three groups.

Competing interests

T Kass-Hout: Genentech. O Kass-Hout: None. M Mokin: None. M Al Masry: None. E Nourollahzadeh: None. A Siddiqui: NINDS 1R01NS064592-01A1, University at Buffalo. Shurtleff, Inc, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra. Codman & Shurtleff, Inc, Genentech. Hotspur, Intratech Medical, StimSox, Valor Medical. Abbott Vascular, American Association of Neurological Surgeons, Neocure Group LLC, an Emergency Medicine Conference. E Levy: Codman & Shurtleff, Inc, ev3/Covidien Vascular Therapies, Boston Scientific. TheraSyn Sensors. Medical Ltd., Mynx/Access Closure. Boston Scientific. K Synder: Toshiba and ev3.
E-080 4D-Flow MRI quantifies hemodynamics in large and giant intracranial aneurysms
Authors: Ansari S , Schnell S , Vakil P , Hurley M , Bendok B , Batjer H , Carroll T , Carr J , Markl M
Published: July 2012

Purpose

Unruptured intracranial aneurysms (IA) are potentially life threatening conditions. Rupture risk based on specific data regarding interval growth or destabilization is lacking. We studied the feasibility of 4D-Flow MRI to analyze 3D flow patterns (vorticity) and aneurysm wall shear stress (WSS) in large and giant IAs.

Materials and Methods

Seven patients (4F:3M, age=3.6±15.4 years) with large IAs (mean diameter=2.6±0.9 cm) were studied. IAs were located near the ICA bifurcation (n=5) or basilar artery (n=2) with saccular, spherical, or fusiform morphology. 4D flow MRI (3T TRIO & 1.5T Avanto, Siemens, Germany, voxel =0.99–1.8×0.78–1.46×1.2–1.4 mm, TE/TR=2.9–3.3/5.5–6 ms, temporal-res=44–48 ms, 3-directional velocity encoding with venc =70–80 cm/s) data were analyzed using Matlab-based tools and 3D blood flow visualization software. The WSS pattern along the aneurysm wall was calculated by cubic spline interpolation of the velocity gradient along the aneurysm contour as described previously. The vorticity defined asVort=abs(ζx,ζy,ζz) (with ζx=δw/δy –δv/δz, ζy=δu/δz–δw/δx, ζz=δv/δx–δu/δy andu,v,wbeing the velocity vector components2) was calculated within the plane transecting the aneurysm.

Results

3D spatial and 3-directional velocity encoding allowed for the 3D visualization of complex intracranial flow patterns. Flow patterns in the aneurysms could be classified in two morphological groups. Narrow high-flow channels in combination with large central low flow regions were identified in five saccular/spherical IAs. Slow flow with less defined flow channels were noted in two fusiform IAs. The distribution of WSS was significantly more heterogeneous and increased and vorticity in the plane through the IA center was significantly higher for saccular/spherical vs fusiform IAs (WSS=0.63N/m2±0.33 N/m2 vs 0.038 N/m2±0.016; Vorticity =0.073±0.028 vs 0.018±0.005; p<0.01).

Conclusion

Our feasibility study shows the potential of 4D flow MRI to identify differences in flow characteristics such as vorticity and WSS patterns in two IA morphology groups which may improve risk stratification and treatment planning.

Competing interests

None.

Abstract E-080 Figure 1Abstract E-080 Figure 2
Facilitating chlamydia testing among young people: a randomised controlled trial in cyberspace
Authors: Kang Melissa , Rochford Arlie , Skinner Rachel , Mindel Adrian , Webb Marianne , Peat Jenny , Usherwood Tim
Published: July 2012

Objectives

Chlamydia notifications have been rising in Australia for over a decade and are highest in young people. This study aimed to evaluate the impact of an internet-based intervention on chlamydia testing among young people 16–25 years.

Methods

In this randomised controlled trial, recruitment, data collection, study interventions and follow-up occurred entirely in cyberspace, facilitated by a website. Eligible participants were aged 16–25 years and resided in Australia. The intervention group received personalised emails inviting interaction about chlamydia testing, while the control group received regular impersonal emails. Primary outcome was self-reported chlamydia testing at 6-month follow-up; secondary outcomes were condom use and changes in knowledge and attitudes.

Results

704 young people completed baseline information, 40 were excluded and five withdrew prior to follow-up. The follow-up rate was 47.3% overall. In the intervention group, 40.6% (95% CI 30.7% to 51.1%) reported having had a chlamydia test at follow-up compared with 31.0% (95% CI 24.8% to 37.2%) in the control group (p=0.07). A per-protocol analysis found that those who engaged in email interaction were more likely to report chlamydia test uptake compared with those in the control group (52.5%, 95% CI 39.3 to 65.4% cf 31.0%, 95% CI 24.8% to 37.2%, p=0.002). There were no differences in secondary outcomes between groups.

Conclusions

This is the first randomised controlled trial undertaken in cyberspace to promote chlamydia testing. E-technology may be useful in promoting chlamydia testing and healthcare seeking behaviour in young people.
Factors associated with sexual debut during adolescence in the Republic of Korea
Authors: Lee Dong-Yun , Moon Jeong Min , Lee Im Soon , Suh Chang Suk , Choi DooSeok
Published: July 2012

Objective

To investigate the factors associated with sexual debut among Korean adolescents.

Methods

Based on a 2008 cross-sectional nationwide online survey conducted in 75 238 Korean middle and high school students aged 12–18 years (39 278 boys and 35 960 girls), demographic profiles of the reproductive health and factors associated with sexual debut were analysed.

Results

The proportion of adolescents who had heterosexual intercourse was 5.1%. The cumulative proportion of sexual debut at age 18 was 20%, and the median age was 17 years. Overall, 0.2% of girls reported past pregnancies, while 8.8% of sexually active girls had ever been pregnant. A proportion of girls who underwent an induced abortion was 89.5%. Up to half (46.0% for boys and 48.3% for girls) never resorted to contraception during coitus. After adjusting for covariates, attendance at general and technical high school, low school record, drinking alcohol, smoking, drug use, high economic status and not living with both parents were associated with the increased proportion of sexual debut in both genders. By contrast, internet use was associated with a reduced risk of adolescent sexual debut.

Conclusion

This study demonstrates the factors associated with sexual debut among Korean adolescents. This information may be helpful for the prevention of unprotected sexual debut and subsequent teenage pregnancy in adolescents who are susceptible to initiating sexual intercourse.
Dietitian-coached management in combination with annual endocrinologist follow up improves global metabolic and cardiovascular health in diabetic participants after 24 months
Authors: Battista Marie-Claude , Labonté Mélissa , Ménard Julie , Jean-Denis Farrah , Houde Ghislaine , Ardilouze Jean-Luc , Perron Patrice
Published: July 2012

This 24 month study evaluated the effect of dietitian coaching combined with minimal endocrinologist follow up on the glycemic control and cardiovascular risks of diabetic participants, compared with conventional endocrinologist follow up. Participants with type 1 or type 2 diabetes were assigned to either the control group with conventional endocrinologist follow up (C; n = 50) or the dietitian-coached group (DC; n = 51) with on-site diabetes self-management education every 3 months combined with annual endocrinologist followup. Over the 24 month intervention, weight (–0.7 vs. +2.1 kg; p = 0.04), BMI (+0.3 vs. +0.7 kg/m2; p = 0.009), and waist circumference (–1.3 vs. +2.4 cm; p = 0.01) significantly differed between the DC and control groups. HbA1Cdropped significantly in participants of the DC versus the control group (–0.6% vs.–0.3%; p = 0.04). This was accompanied by improved overall energy intake (–548 vs. –74 kcal/day; p = 0.04). However, no link associated glycemic control to nutrient intake or intensiveness of pharmacotherapy. Coaching by a dietitian improves glycemic control and reduces certain cardiovascular risk factors in diabetic subjects, demonstrating that a joint dietitian–endocrinologist model of care provides a convenient strategy for cardiovascular risk management in the diabetic population.
A scientific nutrition strategy improves time trial performance by ≈6% when compared with a self-chosen nutrition strategy in trained cyclists: a randomized cross-over study
Authors: Hottenrott Kuno , Hass Erik , Kraus Manon , Neumann Georg , Steiner Martin , Knechtle Beat
Published: July 2012

We investigated whether an athlete’s self-chosen nutrition strategy (A), compared with a scientifically determined one (S), led to an improved endurance performance in a laboratory time trial after an endurance exercise. S consisted of about 1000 mL·h–1 fluid, in portions of 250 mL every 15 min, 0.5 g sodium·L–1, 60 g glucose·h–1, 30 g fructose·h–1, and 5 mg caffeine·kg body mass–1. Eighteen endurance-trained cyclists (16 male; 2 female) were tested using a randomized crossover-design at intervals of 2 weeks, following either A or S. After a warm-up, a maximal oxygen uptake test was performed. Following a 30-min break, a 2.5-h endurance exercise on a bicycle ergometer was carried out at 70% maximal oxygen uptake. After 5 min of rest, a time trial of 64.37 km (40 miles) was completed. The ingested nutrition was recorded every 15 min. In S, the athletes completed the time trial faster (128 vs. 136 min; p ≤ 0.001) and with a significantly higher power output (212 vs. 184 W; p ≤ 0.001). The intake of fluid, energy (carbohydrate-, mono-, and disaccharide), and sodium was significantly higher in S compared with A (p ≤ 0.001) during the endurance exercise. In the time trial, only sodium intake was significantly higher in S (p ≤ 0.001). We concluded that a time trial performance after a 2.5-h endurance exercise in a laboratory setting was significantly improved following a scientific nutrition strategy.
Two maximal isometric contractions attenuate the magnitude of eccentric exercise-induced muscle damage
Authors: Chen Hsin-Lian , Nosaka Kazunori , Pearce Alan J. , Chen Trevor C.
Published: July 2012

This study investigated whether maximal voluntary isometric contractions (MVC-ISO) would attenuate the magnitude of eccentric exercise-induced muscle damage. Young untrained men were placed into one of the two experimental groups or one control group (n = 13 per group). Subjects in the experimental groups performed either two or 10 MVC-ISO of the elbow flexors at a long muscle length (20° flexion) 2 days prior to 30 maximal isokinetic eccentric contractions of the elbow flexors. Subjects in the control group performed the eccentric contractions without MVC-ISO. No significant changes in maximal voluntary concentric contraction peak torque, peak torque angle, range of motion, upper arm circumference, plasma creatine kinase (CK) activity and myoglobin concentration, muscle soreness, and ultrasound echo intensity were evident after MVC-ISO. Changes in the variables following eccentric contractions were smaller (P < 0.05) for the 2 MVC-ISO group (e.g., peak torque loss at 5 days after exercise, 23% ± 3%; peak CK activity, 1964 ± 452 IU·L–1; peak muscle soreness, 46 ± 4 mm) or the 10 MVC-ISO group (13% ± 3%, 877 ± 198 IU·L–1, 30 ± 4 mm) compared with the control (34% ± 4%, 6192 ± 1747 IU·L–1, 66 ± 5 mm). The 10 MVC-ISO group showed smaller (P < 0.05) changes in all variables following eccentric contractions compared with the 2 MVC-ISO group. Therefore, two MVC-ISO conferred potent protective effects against muscle damage, whereas greater protective effect was induced by 10 MVC-ISO, which can be used as a strategy to minimize muscle damage.
Training effects on peripheral muscle oxygenation and performance in children with congenital heart diseases
Authors: Moalla Wassim , Elloumi Mohamed , Chamari Karim , Dupont Grégory , Maingourd Yves , Tabka Zouhair , Ahmaidi Said
Published: July 2012

We investigated the effect of training on peripheral muscular performance and oxygenation during exercise and recovery in children with congenital heart diseases (CHD). Eighteen patients with CHD aged 12 to 15 years were randomly assigned into either an individualized 12-week aerobic cycling training group (TG) or a control group (CG). Maximal voluntary contraction (MVC) and endurance at 50% MVC (time to exhaustion, Tlim) of the knee extensors were measured before and after training. During the 50% MVC exercise and recovery, near-infrared spectroscopy (NIRS) was used to assess the fall in muscle oxygenation, i.e., deoxygenation ([Formula: see text]) of the vastus lateralis, the mean rate of decrease in muscle oxygenation, the half time of recovery (T1/2R), and the recovery speed to maximal oxygenation (RS). There was no effect of time on any parameter in the CG. After training, significant improvements were observed in TG for MVC (101.6 ± 14.0 vs. 120.2 ± 19.4 N·m, p < 0.01) and Tlim (66.2 ± 22.6 vs. 86.0 ± 23.0 s, p< 0.01). Increased oxygenation (0.20 ± 0.13 vs. 0.15 ± 0.07 a.u., p < 0.01) and faster mean rate of decrease in muscle oxygenation were also shown after training in TG (1.22 ± 0.45 vs. 1.71 ± 0.78%·s–1, p < 0.001). Moreover, a shorter recovery time was observed in TG after training for T1/2R (27.2 ± 6.1 vs. 20.8 ± 4.2 s, p < 0.01) and RS (63.1 ± 18.4 vs. 50.3 ± 11.4 s, p < 0.01). A significant relationship between the change in [Formula: see text] and both MVC (r = 0.95, p < 0.001) and Tlim (r = 0.90, p < 0.001) in TG was observed. We concluded that exercise training improves peripheral muscular function by enhancing strength and endurance performance in children with CHD. This improvement was associated with increased oxygenation of peripheral muscles and faster recovery.