bluuebunny/crossref_metadata_2025 huggingface dataset:
O-012 Combined endovascular embolization and stereotactic radiosurgery in the treatment of large arteriovenous malformations
Authors: Blackburn S , Ashley W , Rich K , Simpson J , Drzymala R , Ray W , Moran C , Cross D , Chicoine M , Dacey R , Derdeyn C , Zipfel G
Published: December 2010

Objective

Large cerebral arteriovenous malformations (AVMs) are often not amenable to direct surgical resection or stereotactic radiosurgery (SRS) treatment. An alternative treatment strategy is staged endovascular embolization followed by SRS (Embo/SRS). This study examined the experience at Washington University in St Louis with Embo/SRS for large AVMs, and reviewed results in earlier case series.

Methods

21 patients with large AVMs treated with Embo/SRS between 1994 and 2006 were retrospectively evaluated. AVM size (before and after embolization), procedural complications, radiological outcome and neurological outcome were examined. Radiological success was defined as AVM obliteration by catheter angiography, CT angiography (CTA) or MR angiography (MRA). Radiological failure was defined as residual AVM by catheter angiography, CTA or MRA performed ≥3 years post-SRS.

Results

All AVMs in this series were >3 cm in maximal diameter (mean 4.2 cm); 12 (57%) were high grade (Spetzler-Martin 4 or 5). Clinical follow-up was available in 20/21 patients; radiographic follow-up was available in 19/21 patients (mean follow-up time 3.1 years). Of the 43 embolization procedures performed, eight complications occurred, leading to transient neurologic deficits in five patients (24%), minor permanent neurologic deficits in three patients (14%) and no major permanent neurologic deficits (0%). Of the 21 SRS procedures performed, one (5%) radiation induced complication occurred, leading to a permanent minor neurologic deficit. Of the 20 patients with clinical follow-up, none experienced cerebral hemorrhage. Of the 19 patients with radiographic follow-up, AVM obliteration was confirmed by catheter angiography in 12, MRA in two and CTA in two. Residual nidus was found in three patients. In patients with follow-up catheter angiography, AVM obliteration rate was 80% (12/15).

Conclusions

Embo/SRS provides an effective means of treating large AVMs not amenable to standard surgical or SRS treatment. The outcomes and complication rates reported in this series compare favorably with other reported therapeutic strategies for this very challenging patient population.
O-014 Cerecyte coil trial: the angiographic outcome of endovascular coiling in patients with ruptured and unruptured intracranial aneurysms treated with cerecyte coils compared with bare platinum coils. Results of a prospective randomized trial
Authors: Molyneux A , Fox A , Sneade M , Mehta Z
Published: December 2010

Purpose

To report the 6 month angiographic results in patients treated with Cerecyte or bare platinum coils in a prospective randomized trial.

Materials and methods

500 patients undergoing coil treatment of a ruptured or unruptured cerebral aneurysm in 23 centers in Europe, North America and Japan were randomly assigned to receive either Cerecyte Coils or bare platinum coils. The primary objective was to determine if Cerecyte coils improved the angiographic outcome on follow-up digital angiography 6 months after treatment. Angiographic follow-up was also obtained at 12–24 months after enrollment. Imaging data were transferred to a core laboratory on CD and uploaded into a PACS system and analyzed blind by an experienced neuroradiologist. Secondary objectives included whether Cerecyte coils reduced major recurrence or the need for aneurysm retreatment. Angiographic assessment was carried out by an independent core laboratory blind to the treatment allocation. Success was defined in the protocol as ‘complete angiographic occlusion, improvement or no change in the angiographic appearances from the postprocedural angiography’.

Results

The proportion of patients with success on the primary outcome, minor and major recurrence and retreatment rates will be reported at the first follow-up and the frequency of late recurrence of the second follow-up will be reported for all patients with available data.

Conclusion

The study will provide objective evidence whether Cerecyte coils improve angiographic outcome after coil treatment of cerebral aneurysms.
O-022 Reopening the chronically occluded basilar artery
Authors: Albuquerque F , McDougall C
Published: December 2010

Introduction

Occlusion of the basilar artery (BA) has a poor prognosis. We evaluated technical considerations and complications associated with reopening subacute to chronically occluded BAs.

Methods

Duration of BA occlusion before revascularization, symptoms and medical management before treatment, and postprocedural antiplatelet regimen and anticoagulation protocols of 10 patients were analyzed. All patients underwent attempted Gateway angioplasty followed by Wingspan stenting (Boston Scientific, Fremont, California, USA).

Results

10 patients, including seven men and three women, were treated from 2004 to the present. They ranged in age from 29 to 80 years with a mean of 62. The median time between onset of symptoms to treatment ranged from 4 to 150 days (mean 50 days). Recanalization was successful in 8/10 patients. Immediately following the procedure, seven patients were either improved or stable, and three were worse. Of these three, two died of procedure related complications and one suffered a mild brainstem stroke from which she has made a substantial recovery. A third patient died in a delayed fashion of unrelated causes. Three subacute complications occurred. These included: one acute thrombosis of the stent requiring emergent repeat angioplasty, one symptomatic basilar dissection requiring placement of a second stent 1 week after the original procedure and one mild recurrent stroke after delayed stent occlusion. Of the seven surviving patients, five are improved or stable. The other two patients are mentioned above and suffered a mild brainstem procedurally related stroke and the other a delayed stroke as a result of re-occlusion.

Conclusion

With current endovascular techniques, recanalization of the subacute and chronically occluded basilar artery is feasible. The procedure carries substantial risks and should be reserved for patients with medically refractory symptoms. Careful postprocedural medical management and radiographic follow-up are warranted do prevent in-stent restenosis.
O-024 Clinical outcome in stent versus balloon assisted unruptured aneurysm coiling in the ECOSA Multicenter Study
Authors: Owais M , Zaidat O , Noquiera R , Levy E , Xavier A , Linfante I , Gupta R , Edgle R , Nguyen T , Mueller-Kronast N , Tong F C , Hsu D P , Dion J E , Cawley C M , Batista L M , Natarajan S , Rayes M , Etezadi V , Chowdhry S , Norbash A
Published: December 2010

Background and objective

Cerebral aneurysm with endovascular coil embolization is a well established treatment modality. Endovascular therapy can be complex with primary coiling versus stent or balloon assisted coil embolization. Limited data exist that compares the safety and clinical outcome of balloon versus stent assisted coiling of cerebral aneurysm. This is a substudy of the large Endovascular Coil Embolization of Small Unruptured Cerebral Aneurysm (ECOSA) study comparing stenting versus balloon assisted coiling in a large multicenter cohort.

Method

Data from 11 US medical centers are collected on technical and procedural outcome of unruptured small cerebral aneurysm coiling (<7 mm) with the selection for comparison the subgroups of stenting and balloon assisted coiling. Data on clinical baseline variables and periprocedural outcome of thromboembolic event (TEE) and procedural rupture is collected and compared between the two groups in univariate and multivariate analysis

Results

351 patients were identified to have an adjunctive device use for coiling cerebral aneurysm. 247 underwent stent assisted coiling and 104 underwent balloon assisted coiling.

Mean age of the stenting group was 55.6±11 versus 53.5±12.5 for the balloon group (p value 0.06). The majority were women with 75.7% in the stenting and 77.8% in the balloon group, and the majority were white (73.4%). Mean size of the aneurysm in the stenting group was 5 mm±1.2 mm versus 4.6 1.2 mm for the balloon (p=0.003).

Overall events rate of all TEE and rupture complications were 4.2% for the stenting versus 1.6% for the balloon (p=0.02); there was a difference in the symptomatic complication of TEE or rupture.

Conclusion

Contrary to the other literature, in our retrospective large case series comparing stent versus balloon assisted coiling, the event rate of TEE and rupture were significantly higher in the stent group. A larger prospective study is needed to confirm this result.
O-025 The Trevo device: preclinical data of a novel stroke thrombectomy device in two different animal models of arterial thrombo-occlusive disease
Authors: Nogueira R , Levy E , Gounis M , Siddiqui A , Duckwiler G
Published: December 2010

Introduction

The currently available mechanical devices fail to achieve recanalization in as many as 20–40% of proximal arterial occlusion strokes. We now report on the preclinical evaluation of the safety and efficacy of a novel thrombectomy device designed to achieve immediate flow restoration by quickly removing clot.

Methods

Four confirmatory animal studies were performed with the Trevo Device (Concentric Medical Inc, Mountain View, California, USA) in the swine (n=2) and canine (n=1) models of arterial thrombo-occlusive disease employing autologous thrombin generated thrombi. The angiographic response and the degree of device clot incorporation were evaluated. High resolution flat panel three-dimensional CT was performed to further define the in vivo device–thrombus–vessel interaction. Finally, samples of three swine vessels treated with six passes of the device were explanted for histopathological analysis.

Results

A total of 16 clots of variable hardness and consistency were implanted in a variety of vascular settings, including the swine internal maxillary, lingual and forelimb arteries as well as the canine external carotid and vertebral arteries. TIMI 2–3 reperfusion was achieved in all cases immediately after device deployment. All 16 clots were retrieved after one (n=15) or two (n=1) passes with the device. Histopathological analysis demonstrated severe disruption of the intima but no hemorrhage of media or adventitia.

Conclusion

Our experimental data suggest that the Trevo Device is highly effective at achieving immediate reperfusion of occluded arteries without causing any clinically significant disruption of the vascular integrity. Initial human clinical evaluations of the Trevo Device in acute ischemic stroke patients are underway.

Abstract O-025 Figure 1

Example of in vivo device–clot–blood vessel interaction. (A) Road map angiography of the swine left lingual artery. (B) High resolution flat panel CT three dimensional reconstruction. Arrows: proximal (black) and distal (white) radiopaque markers of the Trevo Device. Arrowhead: radiopaque thrombus. (C) Axial cut reconstruction of the area identified by the arrowhead in (B) showing complete incorporation of the radiopaque thrombus (arrowhead) through the struts of the Trevo Device.
O-026 Balloon assisted coiling of intracranial aneurysms: complication comparison between non-assisted and balloon assisted procedures
Authors: Perl J , Fease J , Tubman D , Crandall B
Published: December 2010

Background and purpose

There is still a question in the current literature as to whether the addition of balloon assistance in intracranial aneurysm embolization procedures increases thromboembolic and intraoperative perforation complications. The purpose of this study was to determine if balloon assisted coiling (BAC), given the use of an additional device, increases complications compared with conventional coiling of intracranial aneurysms.

Methods

Between June 2002 and February 2010, 845 consecutive intracranial aneurysm embolization procedures were assessed. Of these procedures, 640 (207 ruptured) procedures had a high compliant balloon (Hyperform (73.8%) or Hyperglide (25.8%); eV3 Corp) inserted during the procedure; 205 (127 ruptured) procedures had no adjunctive devices inserted during the course of the procedure. Procedures utilizing stent assistance were excluded from the study. Procedures were performed by three different interventionalists at a single center. Procedural thromboembolic complications, intraoperative perforations, hospital course complications and Glasgow Outcome Score were reviewed and recorded retrospectively and prospectively. Comparisons between the techniques were also made between ruptured and unruptured aneurysms. Results were analyzed using the Student t test; p values <0.05 were considered statistically significant.

Results

With BAC, 88.8% of procedures had no complications whatsoever (85.0% ruptured, 90.5% unruptured) and with conventional coiling, 84.9% (80.1% ruptured, 92.3% unruptured) (p=0.168) of procedures had no complications. Thromboembolic complications with clinical sequelae occurred more during conventional coiling (7.3%; 15/205) than BAC (1.1%; 7/640) (p=0.001). Intraoperative perforation occurrences were not statistically significantly different (2.8% BAC versus 1.5% conventional coiling; p=0.20)). Of the intraoperative perforations with BAC, only 38.9% (7/18) occurred while the balloon was inflated. In 33.3% (6/18), the balloon was inflated only after perforation by coil or microcatheter. In 11.1% (2/18), the balloon was only inserted after the perforation had occurred, 5.6% (1/18) occurred during angioplasty and in 11.1% (2/18) extravasation was seen immediately after procedure termination. In the BAC procedures, 94.8% had no hospital course complications (90.8% ruptured, 96.8% unruptured) and in conventional coiling procedures, 85.9% (78.0% ruptured, 98.7% unruptured) had no hospital course complications. Glasgow Outcome Score in ruptured and unruptured aneurysms showed no statistically significant difference in BAC procedures compared with conventional coiling procedures.

Conclusion

The use of balloon assistance in intracranial aneurysm embolization procedures does not increase technical or clinical complications compared with embolization procedures without balloon assistance.
O-027 Predictors of restenosis and periprocedural strokes during intracranial stent placement: a retrospective multicenter study
Authors: Hussain M , Kalia J , Malik A , Ching E Cheng , Teng Q , Lin R , Jovin T , Zaidat O , Gupta R
Published: December 2010

Background and purpose

Intracranial stenting and angioplasty has been increasingly utilized for the treatment of symptomatic intracranial atherosclerotic disease (ICAD). The use of self-expanding stents (SES) has been reported to have a high technical success rate but there are concerns with restenosis. We sought to determine if the use of balloon mounted stents (BMS) was associated with higher technical complication rates compared with self-expanding stents.

Methods

Three academic institutions contributed data on patients treated for symptomatic ICAD over a 3 year period (2006–2009). 259 consecutive patients were identified. Demographics, type of stent placed, periprocedural complications, per cent stenosis prior to treatment and after treatment, if the treatment was within 2 weeks of clinical symptomatology, lesion classification with the Mori scale and follow-up imaging for restenosis were collected retrospectively. A univariate analysis was performed to determine predictors of periprocedural stroke and also for restenosis at follow-up. Variables with a p value <0.20 were entered into a binary logistic regression model to indentify independent predictors.

Results

259 patients with a mean age of 61±13 years with 168 (65%) patients presenting with strokes and the rest with transient ischemic attacks. The distribution of the lesions were as follows: vertebrobasilar 109 (42%), middle cerebral artery 85 (33%) and intracranial internal carotid artery 65 (25%). 79 (31%) BMS were implanted and 180 (69%) SES. A total of 17 (6.5%) patients developed a periprocedural stroke with no difference noted between use of type of stent. Patients in whom a BMS was implanted had a significant reduction in stenosis compared with SES (81±10% to 7±11% vs 80±12% to 24±9%; p<0.0001). The independent predictors of periprocedural stroke were as follows: treatment within 2 weeks (OR 2.5 (1.2 to 5.6); p<0.01), Mori B or C lesion (OR 6.7 (3.3 to 10.1); p<0.001) and patients with an index event of a stroke (OR 1.5 (1.2 to 3.4); p<0.018). The independent predictors of restenosis at follow-up were as follows: use of SES (OR 3.22 (1.40 to 7.41); p<0.006) and Mori B or C lesion (OR 3.97 (2.05 to 7.71); p<0.0001).

Conclusions

The use of BMS was not associated with higher complication rates but was associated with lower restenosis rates. Placement of stents in patients with more complex lesions is associated with higher periprocedural stroke rates and restenosis. Further prospective studies comparing BMS with SES are warranted.
O-032 Long-term outcomes in emergent cavernous carotid stent grafting: a series of 29 cases
Authors: Alexander M , Choulakian A
Published: December 2010

Introduction

Traumatic injury to the cavernous carotid artery may be difficult to manage as it often requires emergent treatment due to the potential for life threatening hemorrhage. Since this segment of artery is difficult to access surgically, frequently endovascular treatment by either parent artery occlusion or stent grafting is necessary.

Methods

This is a prospective case series of 29 patients who had traumatic cavernous carotid injury or spontaneous hemorrhage who had placement of one or more stent grafts in the cavernous carotid artery for treatment. Patients were loaded with either 300 mg or 600 mg of clopidogrel and 325 mg of aspirin either a few hours prior to the endovascular procedure or via an oral gastric tube at the time of the procedure. Patient also received intraprocedure intravenous heparin. They were then maintained on clopidogrel and aspirin for 6 months and then aspirin alone from then on. Follow-up imaging was performed at 6 months post intervention, and patients were then followed up clinical on an annual basis.

Results

Of the 29 patients who had treatment, 10 patients had iatrogenic injury to the carotid artery from surgery with epistaxis, 14 patients had direct traumatic carotid cavernous fistula and two patients had epistaxis or subarachnoid hemorrhage from a gunshot wound. Three patients had prior malignant skull base tumor resection with radiation therapy that developed acute epistaxis. Two of the patients developed thromboembolic events within the first 30 days of treatment. With an average imaging follow-up of 2.7 years, two patients had asymptomatic occlusion of their stent grafts, 22 patients had patent stent grafts and five patients had no imaging follow-up.

Conclusions

Stent grafts provide a safe alternative to deliberate parent artery occlusion in patients with spontaneous hemorrhage or traumatic to the cavernous carotid artery. With aggressive antiplatelet therapy, a long term symptomatic thromboembolic rate of 7% was seen.
O-004 The pattern of leptomeningeal collaterals on CT angiography is a strong predictor of good functional outcome in stroke patients with intracranial large vessel occlusion
Authors: Lima F , Furie K , Silva G , Lev M , Camargo É , Ay H , Singhal A , Harris G , Halpern E , Koroshetz W , Smith W , Yoo A , Nogueira R
Published: December 2010

Background and purpose

The role of non-invasive methods in the evaluation of collateral circulation has yet to be defined. We hypothesized that a favorable pattern of leptomeningeal collaterals, as identified by CT angiography (CTA), correlates with improved outcomes.

Methods

Data from a prospective cohort study at two university based hospitals where CTA was systematically performed in the acute phase of ischemic stroke were analyzed. Patients with complete occlusion of the intracranial internal carotid artery and/or the middle cerebral artery (segments M1 or M2) were selected. Leptomeningeal collateral pattern was graded as a three category ordinal variable (less, equal or greater compared with the unaffected contralateral hemisphere). Univariate and multivariate analyses were performed in order to define the independent predictors of good outcome at 6 months (modified Rankin Score (mRS) ≤2).

Results

196 patients were selected. Mean age was 69±17 years and median National Institutes of Health Stroke Scale (NIHSS) score was 13 (IQR 6–17). In the univariate analysis, age, baseline NIHSS, pre-stroke mRS, Alberta Stroke Programme Early CT Score, admission blood glucose, history of hypertension, coronary artery disease, congestive heart failure, atrial fibrillation, site of occlusion and collateral pattern were predictors of outcome. In the multivariate analysis, age (OR 0.95; 95% CI (0.93–0.98); p=0.001), baseline NIHSS (OR 0.75; 0.69–0.83; p<0.001), pre-stroke mRS (OR 0.41; 0.22–0.76; p=0.01), intravenous recombinant tissue plasminogen activator (OR 4.92; 1.83–13.25; p=0.01) and leptomeningeal collaterals (OR 1.93; 1.06–3.34; p=0.03) were identified as independent predictors of good outcome.

Abstract O-004 Figure 1

Examples of robust and poor leptomeningeal collaterals. (A) Good leptomeningeal collaterals: 51-year-old male, initial National Institutes of Health Stroke Scale (NIHSS) of 12, modified Rankin score at 6 months: 1. (B) Poor leptomeningeal collaterals: 47-year-old female, initial NIHSS of 13, modified Rankin score at 6 months: 6. Arrows point to the site of occlusion at the middle cerebral artery (MCA)–M1. The strength of leptomeningeal collaterals is estimated by the degree of distal reconstitution of the MCA vessels.

Conclusion

Consistent with angiographic studies, leptomeningeal collaterals on CTA are also a reliable marker for good outcome in acute ischemic stroke patients presenting with large vessel occlusion. The acquisition of this information does not require any extra time or processing and may greatly assist in the selection of patients who are potential candidates for endovascular treatment.
O-005 Solitaire FR stent used as a revascularization device in acute ischemic stroke. Acute results: Montpellier preliminary experience
Authors: Machi P , Costalat V , Riquelme C , Maldonado I , Bonafé A
Published: December 2010

Background and purpose

Prompt recanalization of occluded brain arteries in patient victims of acute ischemic stroke (AIS) is associated with a better clinical outcome. Several trials have assessed the efficacy and safety of intra-arterial (IA) mechanical thrombectomy combined with intravenous (IV) administration of thrombolytic drugs in the therapy of AIS. The aim of this work is to evaluate the efficacy and the safety of Solitaire FR (SFR) (ev3 Inc, Irvine, California, USA) as a revascularization device in the treatment of AIS in combination with IV administration of thrombolytic drugs.

Materials and methods

Data of 21 patients treated with SFR within 7 h of AIS symptom onset in the setting of a prospectively defined IV–IA combined therapy were analyzed.

Results

SFR was successful to achieving complete recanalization in 19 patients (90.4%) with a final score of 3 according to the Thrombolysis in Myocardial Infarction (TIMI) classification. Partial recanalization (TIMI2) was obtained in one patient (4.7%). Treatment failure was observed (TIMI0) in one patient (4.7%).

Four adverse events were recorded (21%): two intraprocedural thromboembolic events (10.5%) and two symptomatic intracranial hemorrhagic infarctions (10.5%). One patient died during the hospitalization due to massive brainstem infarction.

Marked improvement of National Institutes of Health Stroke Scale from baseline to 24 h after recanalization was obtained in 12 patients (57.1%).

Conclusions

SFR was effective in achieving a high rate of complete artery recanalization with a low rate of complications. SFR may be considered as a promising tool for endovascular cerebral thrombectomy.
O-006 A novel microcatheter based device for endovascular mechanical thrombectomy/flow restoration
Authors: Tateshima S , Zauner A , Barr J , Lopes D , Liebeskind D
Published: December 2010

Purpose

To evaluate the performance of a new microcatheter based device (ReStore, Reverse Medical, Irvine, California, USA) for endovascular mechanical thrombectomy/flow restoration in a swine thromboembolic model and to compare its efficacy over other available devices for mechanical thromboembolectomy.

Method

We investigated the use of ReStore for thrombectomy treatment against similar control devices. The cerebral vasculature swine model was utilized in which 12 of each carotid artery branches were prepared with prophylactic papaverine due to the vasospastic nature of the swine model and occluded with radio-opacified blood thrombi. The thrombi were prepared in such a way to represent characteristics of those found in acute stroke patients. The thrombi were injected into target arteries via a 6 Fr guiding catheter. The thrombi were allowed to set up in situ for at least 15 min until complete localized occlusion of the target vessels were confirmed by angiography. Once the occlusion was confirmed, ReStore or a control device was advanced via a 6 Fr guide catheter and precisely positioned across the target thrombi over a microguide wire. No flow arresting means was utilized during retrieval or recanalization attempts. Only localized aspiration was conducted via the 6 Fr guide catheter, once the ReStore or control device holding retrieved thrombi was pulled down to the tip of the guide catheter. Parameters collected for this assessment study were TIMI score, number of retrieval attempts, per cent clot retrieved, time to recanalization, thrombus fragmentation and loss of thrombus at the tip of the guide catheter.

Results

We found higher TIMI scores (OR 9; 95% CI 0.28 to 285.3), recanalization on the first attempt (9/10 vs 0/2; p<0.01) and per cent clot retrieved (74% vs 20%; p=0.06) with ReStore over the control devices while procedure times for ReStore appeared to be the same as that of the control device. Despite the use of prophylactic papaverine, vasospasm was still prevalent in all cases, even during guidewire and catheter manipulations. No vessel dissections or device failures were encountered during this study. Study recanalization rates for ReStore (9/10, 90%) in the swine model, which is much less tortuous than humans, and the radio-opacified thrombi allowed for more accurate target positioning and retrieval.

Conclusion

ReStore is effective in removal of thrombi and recanalization of blood flow within the swine cranial arteries.

Abstract O-006 Figure 1
E-001 Utility of flexible guide catheter in assisting transvenous superior ophthalmic vein catheterization and embolization of difficult to treat carotid–cavernous/orbital fistulas
Authors: Gandhi D , Kathuria S , Subramanian P , Miller N , Huang J
Published: December 2010

Introduction

Dural type fistulas of the cavernous sinus are complex lesions; transvenous embolization is often favored but may be difficult to accomplish if there is thrombosis, stenosis or occlusion of the drainage pathways. Surgical access to the superior ophthalmic vein (SOV) is very helpful in case of difficult endovascular access to the cavernous sinus. However, it is associated with a small but additional risk. This includes inability to cannulate the SOV or treat the fistula and less commonly intraorbital hemorrhage. With the availability of newer, flexible, distal access guide catheters, these difficult to treat cases could possibly be treated using exclusively endovascular approach.

Materials and methods

During the past 2 years, eight patients with symptomatic cavernous sinus fistulae were endovascularly treated by one of the authors (DG). Three of the seven lesions were considered difficult to treat using transvenous access on account of thrombosis/occlusion of the inferior petrosal sinus and presence of unfavorable angle and/or severe stenosis at the junction of the SOV with the angular vein. One of three patients had a previous failed attempt at embolization using the angular/facial vein approach. Embolization was performed in all three patients using the middle temporal vein (2/3) or facial/angular vein (1/3), with flexible, distal access guide catheters.

Results

Successful catheterization of the SOV was facilitated using a combination of flexible distal access catheter (neuron or Merci distal access catheter) and a microcatheter. The flexible, guide catheters could be advanced very distally and just short of the junction of the angular vein and SOV (1/3) and supraorbital vein and SOV (2/3). This provided a stable platform and enhanced the microcatheter navigation into otherwise difficult to access SOVs. All lesions were successfully treated with this approach.

Conclusion

Distal access flexible guide catheters can be advanced across tortuous venous anatomy and can even reach just short of the SOV. This helps in providing a markedly stable platform and helps superselective microcatheterization of the SOV. With the help of these newer guide catheters, many of the difficult to treat carotid–cavernous fistulas could possibly be treated using an exclusive endovascular approach thereby avoiding the need for direct surgical exposure of the SOV.
E-012 Six year single center experience with the treatment of spinal dural fistulae
Authors: Chaudhary N , Gemmete J , Pandey A , Ansari S , Thompson B
Published: December 2010

Introduction and purpose

Surgical disruption has been the traditional method for treatment of spinal dural fistulae. Currently the natural history of spinal dural fistula is not clearly understood. There are a few case series reported in the literature documenting successful endovascular treatment of spinal dural fistula with n-butyl cyanoacrylate (n-BCA) liquid embolic material. A relatively new liquid embolic agent ethylene vinyl alcohol (Onyx) has been used extensively in the endovascular treatment of cerebral arteriovenous malformation and dural arteriovenous fistula. The first application of Onyx in the endovascular treatment of a spinal dural fistula was reported in the literature in 2003. An additional three cases of spinal dural fistula treated successfully with Onyx were reported in 2009. We present our experience with endovascular treatment of spinal dural fistula using n-BCA and more recently Onyx.

Materials and methods

We performed a retrospective review of all spinal dural fistulae cases that were treated at our institution from February 2004 to February 2010. Patient chart review, outpatient clinic follow-up letters and imaging review formed the retrospective analysis for the identified group of patients. 14 patients were identified with a spinal dural fistula. There were nine men and five women in the cohort. The age ranged from 16 to 81 years (mean 57 years). 13 were confirmed on digital subtraction spinal angiography (DSA) and one was negative on DSA.

Results

14 cases of spinal dural fistulae were treated. Three cases had to undergo surgical disruption due to the proximity of the anterior spinal artery to the arterial feeder to the fistula. All surgical cases were marked with coils in the anterior division of the intercostal artery to facilitate level identification. The 11 patients treated by endovascular embolization had a total of 14 procedures. Onyx was used as the liquid embolic agent in four cases while seven endovascular embolizations were performed utilizing n-BCA and coils. There were no procedure related complications associated with endovascular treatment. The mean follow-up of the cohort was 15 months (range 10 days–52 months). Nine of the 14 cases treated had symptomatic improvement and five were stable after treatment. All of the cases treated with Onyx had marked improvement in clinical symptoms.

Conclusion

Endovascular treatment of spinal dural fistula with liquid embolic agents is safe and effective. Surgical disruption should be performed when endovascular treatment risks iatrogenic injury or is not technically possible. Onyx may be an alternative to n-BCA when encountering inaccessible arterial feeders due to anatomic tortuosity. Utilization of the unique properties of Onyx may allow the safe treatment of spinal dural fistulae from a relatively proximal location.
E-013 Novel dual approach treatment of an internal carotid artery traumatic pseudoaneurysm
Authors: Turk A , Vandergrift A , Chaudry I , Turner R
Published: December 2010

Background

Traumatic pseudoaneurysm formation related to transection of the internal carotid artery is an uncommon injury associated with skull base fractures. Rarely these aneurysms can extend through the fracture site and into the spheoid sinus. While stenting is a documented approach for addressing the vascular injuries, it is of limited use in treating aneurysms that project into the paranasal sinuses. Standard coiling is also of limited utility due to the lack of surrounding structures for support and, therefore, is prone to certain recurrence. Due to the curvature of the carotid siphon and the close proximity of the ophthalmic artery, placement of a covered stent is not feasible with current technology. The use of flow diverting devices may be beneficial but are not commercially available at this point and the long term implications are not fully understood. We present a novel method of combined endoscopic and endovascular techniques for treating these dangerous lesions.

Materials and methods

A 23-year-old woman involved in a motor vehicle accident with traumatic brain injury began experiencing epistaxis 3 weeks after her injury. The ENT service felt the source to be related to the left posterior nasal septum and embolization was requested. Diagnostic cerebral angiography revealed a 5 mm pseudoaneurysm projecting from the internal carotid artery into the sphenoid sinus. The distal internal maxillary artery was unremarkable but was embolized due to continued concern for a septal source of epistaxis. The next day the aneurysm was coiled with balloon assistance with good immediate angiographic result. The patient was taken the following day to the operating room and the sphenoid sinus was endoscopically opened, packed with denuded nasal mucosa harvested from the nasal cavity and reinforced with fat and then sealed with a bone fragment. The next day the patient was loaded with Plavix and aspirin, and a Neuroform stent was placed across the injured vascular segment and aneurysm neck.

Results

The aneurysm was angiographically well treated without residual during the initial coil procedure. There was irregularity of the carotid artery adjacent and distal to the aneurysm, likely representing further regions of injury. Surgically reinforcing the sphenoid sinus did not alter the angiographic appearance of the aneurysm. Placement of a stent across the aneurysm and adjacent areas of injury did not result in any acute angiographic changes. The patient did not suffer any adverse neurologic sequelae. Follow-up angiography is pending and will be presented if available.

Conclusion

Traumatic pseudoaneurysms projecting into the paranasal sinuses can be safely and perhaps more efficaciously treated with a combined endoscopic and endovascular approach.
E-019 Novel bioactive coil with modified PGLA
Authors: Kan I , Yuki I , Murayama Y , Vinuela F , Kim R , Zhang B , Wu B , Vinters H , Vinuela F
Published: December 2010

Purpose

Novel Bioactive Coil with modified PGLA was developed to further improve biological reaction induced by currently available PGLA coils.

Method

Prototype coil materials were prepared by coating the currently available PGLA coils (matrix coil) with chemically modified PGLA. A total of 12 side wall aneurysms were surgically created in six swine. Four aneurysms were treated with Novel Bioactive Coil, four aneurysms were treated with 90/10 PGLA coils and four aneurysms were treated with bare platinum coil (Gugliemi Detachable Coils), respectively. All animals were kept alive for 14 days after the procedure. Histologic as well as immunohistochemical analyses were performed on each harvested sample.

Results

Macroscopic findings showed that significantly advanced thrombus organization was observed in the Novel Bioactive Coil group compared with the PGLA coil group and the bare platinum coil group. The granulation tissue induced by Novel Bioactive Coil was characterized by its intensive migration of multinuclear giant cells, profound microvascular proliferation and vacuole formation around the coil materials. Qualitative histological analysis showed that Novel Bioactive Coil elicited the most prominent macrophage expression, followed by PGLA coils and bare platinum coil.

Conclusion

Novel Bioactive Coil has a potential to elicit more accelerated thrombus organization compared with currently used coil materials, including bare platinum coil and PGLA coil.

Abstract E-019 Figure 1
E-002 Initial experience with the Penumbra stroke system for recanalization of large vessel occlusions in acute ischemic stroke
Authors: Menon B , Hill M , Eesa M , Modi J , Bhatia R , Wong J , Hudon M , Morrish W , Demchuk A , Goyal M
Published: December 2010

Background

The Penumbra system is a newly approved mechanical device for the treatment of acute stroke designed for better and faster recanalization. We describe our initial experience with the use of this device.

Methods

We studied 27 consecutive patients with acute ischemic stroke from January 2009 to October 2009 at our stroke centre. The primary outcome was the degree of reperfusion (TIMI grade 2/3) at end of the procedure. Secondary end points were the proportion of patients who achieved a modified Rankin Scale (mRS) ≤2 at 3 months, all cause mortality and intracerebral hemorrhage (ICH) on non-contrast CT at 24 h. Procedural complications such as vascular perforations, vasospasm, dissection, distal embolization and groin complications were recorded.

Results

27 patients (13 men, mean age 61 years) were treated during the period January–October 2009. Median National Institutes of Health Stroke Scale on admission was 18 (range 3–32), median Alberta Stroke Program Early CT Score on non-contrast CT at admission was 8 (range 5–10) and median onset to intra-arterial treatment time was 192 min. 22 (81%) patients had anterior circulation strokes. 17 (63%) had intravenous tissue plasminogen activator initiated prior to angiography. 85% (23/27) patients achieved TIMI 2/3 grade reperfusion at completion of the procedure. 48% (13/27) patients had mRS ≤2 at the 3 month follow-up. Procedural complications included vasospasm (1/27), distal emboli (13/27) and ICH (seven HI1, one PH1 and one PH2). All cause mortality was 19% (5/27).

Conclusions

High reperfusion rates and good clinical outcomes are achievable with the Penumbra system. Complication rates are comparable with the previously published literature.
E-021 Percutaneous vertebroplasty for osteoporotic fractures: experience with high viscosity cement using a hydrolic injection device, the ‘CONFIDENCE’ system
Authors: Georgy B
Published: December 2010

Purpose

Vertebroplasty is a widely used technique to treat painful osteoporotic vertebral compression fractures but precise control of cement delivery is necessary to minimize the risk of cement leakage. The study is conducted to assess the clinical feasibility of performing vertebroplasty on osteoporotic compression fractures using an ultraviscous cement injected by a hydrolic device, CONFIDENCE Vertebral Augmentation System, to further control cement deposition.

Material and method

A retrospective evaluation of a series of 94 consecutively treated patients was identified for the review. There were a total of 163 levels which ranged from T3 to L1 vertebral bodies. The degree of leakage, seen in the postoperative films, was assessed at each treated level using a strict 4 point scale (none, minimal, moderate, severe). The pattern of any observed leakage was also characterized as: distal, venous, paravetebral or epidural.

Results

Preoperatively the mean degree of vertebral collapse was 29%. A bipedicular approach was used for 82% (133/163) levels and unipedicular in 18% (30/163). There was no leakage in 50%, minimal leakage in 42% and moderate leakage noted in 8% of cases. Both unipedicular and bipedicular approaches showed leaks in 50% of cases. The most frequent pattern of leak was venous indicated in 52% of leaks, the adjacent disc in 46% and paravertebral in 5%. The pattern of leakage was always limited to one region except in two cases. There were no symptomatic leaks that required surgical intervention.

Conclusions

Vertebroplasty in osteoporotic fractures using a highly viscous cement that can be safely controlled and injected via a hydrolic system can be performed safely without significant complications.
E-022 Single institutional experience with placement of a compliant guide catheter into extremely distal locations within the intracranial and extracranial vasculature to facilitate treatment of various neurovascular pathologies
Authors: Gemmete J , Chaudhary N , Pandey A , Thompson B , Ansari S
Published: December 2010

Introduction and purpose

Access to the intracranial pathology through tortuous vasculature has often been the limiting factor in treating certain patients. To address this issue, the 6 French Neuron (0.053 inches) delivery catheter (Penumbra Inc, Alameda, California, USA) was developed to provide greater proximal guide support and enable distal microcatheterization of the intracranial vasculature. A few articles have described the technique but guide positions in these publications were below the level of the dura. The purpose of this paper is to describe our experience with very distal placement of the guide catheter within the intracranial and extracranial vasculature enabling treatment of various neurovascular pathologies.

Materials and methods

In 12 patients, attempts were made to initially treat the neurovascular pathology with a standard guide catheter and microcatheter but they were unsuccessful either due to tortuous supra-aortic, cervical, extracranial or intracranial vasculature. The 6 F Neuron delivery catheter was substituted through a 6 F sheath for greater distal purchase and support.

Results

The 6 F Neuron guide catheter was delivered in very distal vascular locations providing excellent support for advancement of the microcatheter and treatment of the lesion. The guide catheter was positioned in the following locations for treatment: origin of ophthalmic artery, M1 segment, M2 segment, A1 segment, P1 segment, basilar artery, origin of the anterior inferior cerebellar artery, distal internal maxillary artery, distal occipital artery, distal superficial temporal artery, cavernous sinus and distal superficial temporal vein. Three patients were treated for carotid cavernous fistula, three patients for arteriovenous malformations, three patients for dural arteriovenous fistulas, two patients for intracranial aneurysms and one patient for vasospasm following subarachnoid hemorrhage. There was no evidence of vasospasm or complications related to the distal position of the guide catheter.

Conclusion

Utilization of the guide catheter in extremely distal positions is safe and effective, allowing for treatment of traditionally inaccessible lesions. The guide catheter allows for more distal placement and greater proximal support to access neurovascular lesions in the setting of tortuous cervical and/or intracranial vasculature.
E-023 Progressive occlusion in aneurysms treated with stent assisted coiling: flow diversion?
Authors: Izar B , Rai A , Carpenter J , Raghuram K
Published: December 2010

Background

Treatment of intracranial aneurysms using stent assisted coiling (SAC) has broadened the range of endovascular therapies for these aneurysms.

Objective

Our goal was to assess the long term durability of SAC with specific attention to progressive aneurysm occlusion anecdotally observed in these patients.

Materials and methods

A total of 84 aneurysms in 80 patients were initially assessed. Of these, 59 patients on whom long term follow-up was available were included. Immediate post-treatment and follow-up angiograms were evaluated by two independent observers and graded for aneurysm coil coverage (>95%; 85–95%, <85% of the aneurysm volume containing any loop of coil) and intra-aneurysmal flow (no flow, neck remnant, flow beyond the neck). Aneurysm morphology (spherical vs ellipsoid), orientation (sidewall vs bifurcation) and volume were also recorded, as was the packing density of the coil mass. Progressive occlusion was defined as decreased intra-aneurysmal flow or increased coil coverage on the follow-up angiogram.

Results

The mean follow-up duration was 20.6 months (range 1.2–57.2 months). The mean aneurysm size was 8.4 mm (maximum dimension) and the mean packing density was 32.6%. On the initial treatment, >95% coil coverage was achieved in 81% of patients. On the immediate post-treatment angiogram, 71.1% of the patients had either no intra-aneurysmal flow or flow at the neck while 28.9% demonstrated flow beyond the neck. On the follow-up study, however, 91.5% of the patients had no flow or flow limited to the neck while the percentage of patients with flow beyond the neck was reduced to only 8.4%. Thus 35.6% (21/59) of patients demonstrated progressive reduction in the intra-aneurysmal flow on follow-up imaging. The most important predictor for progressive aneurysm occlusion was the aneurysm orientation; side wall aneurysms demonstrating a higher propensity for progressive occlusion than bifurcation aneurysms (p=0.02). This was independent from aneurysm volume, packing density and initial coil coverage. After orientation, aneurysm shape was the strongest predictor, with a spherical shape showing greater progressive occlusion than a complex or ellipsoid shape (p=0.05).

Conclusion

Sidewall aneurysms with a relatively homogeneous shape have the greatest propensity of showing progressive aneurysm occlusion when treated with SAC. This could possibly be secondary to a higher degree of flow diversion seen in the side wall as opposed to bifurcation aneurysms. This is also important because in these aneurysms leaving a neck remnant or small amount of intra-aneurysmal flow as opposed to taking the added risk of complete occlusion by additional coils may be a safe choice.