bluuebunny/crossref_metadata_2025 huggingface dataset:
P-021 Endovascular treatment of wide necked intracranial aneurysms using microcatheter protective technique: techniques and outcomes in 71 aneurysms
Authors: Lee J , Cho Y , Kwon B , Han M
Published: December 2010

Introduction

Catheter protective technique, an adjunctive technique of multiple microcatheter techniques, means positioning an additional microcatheter, instead of a balloon or stent, in the parent or side branching arteries to protect them during coil embolization. The purpose of this study was to describe a microcatheter protective technique and to evaluate the radiologic and clinical outcomes.

Materials and methods

From January 2003 to January 2010, 330 patients harboring 336 wide neck aneurysms were treated with detachable coils using multiple microcatheter techniques. 71 (21.1%) of 336 aneurysms were treated with a catheter protective technique. The aneurysms were in the following locations: middle cerebral artery (22, 31%), anterior communicating/anterior cerebral arteries (17, 23.9%), basilar artery bifurcation (13, 18.3%), posterior communicating artery (nine, 12.7%), anterior choroidal artery (four, 5.6%), internal carotid artery bifurcation (three, 4.2%), vertebral/posterior inferior cerebellar arteries (two, 2.8%) and posterior cerebral artery (one, 1.4%). Ten (14.1%) aneurysms were presented with subarachnoid hemorrhage and 61 (85.9%) were unruptured. The mean aneurysm neck size was 3.9±1.7 mm (range 1.9–13.8 mm) and the mean dome to neck ratio was 1.1±0.3 (range 0.7–2.8). Imaging follow-up, including plan radiography, magnetic resonance angiography or digital subtraction angiography, ranging from 3 to 36 months, was available in 57 (80.3%) patients, with a mean of 14.7±8.8 months. Immediate postprocedural completion angiograms were evaluated using a conventional angiographic scale. Clinical evaluations were performed using a Glasgow outcome scale.

Results

Immediate postprocedural angiograms demonstrated total occlusion of the aneurysm in 42 (59.2%) aneurysms, neck remnant in 16 (22.5%) and body filling in 13 (18.3%). There were 11 (15.5%) thromboembolic events that were treated with intra-arterial infusion of tirofiban. One (9%) of these 11 patients had a permanent neurologic deficit (sensory dysphasia). There was no significant difference in the rate of thromboembolic events between the parent artery protecting and side branching artery protecting groups (11.1% vs 17.6%; p=0.71). One patient died and the other patient was severely disabled from complications which were not related to the procedure, secondary to subarachnoid hemorrhage. All patients, except three complicated cases mentioned above, showed excellent clinical outcomes. Of the 57 aneurysms with follow-up, recanalization was developed in five (8.8%) aneurysms, and three (5.3%) cases of major recanalization were retreated endovascularly.

Conclusion

The microcatheter protective technique is feasible and safe for coil embolization of wide neck aneurysms, especially in cases which are not suitable for the multiple catheter technique, balloon remodeling technique or stent assisted technique.
O-010 Effective minimally invasive treatment of moderate lumbar spinal stenosis with the superion interspinous spacer
Authors: Rappard G , Block J , Miller L , Chiu J , Bini W
Published: December 2010

Introduction and purpose

Mild lumbar spinal stenosis (LSS) is treated with conservative measures although long term success remains elusive. Patients with severe radicular symptoms often require surgical intervention. However, there is a significant therapeutic void for patients with moderate LSS. The purpose of this study was to evaluate the preliminary effectiveness and safety of the Superion Interspinous Spacer (Vertiflex, Inc, San Clemente, California, USA) in patients with moderate LSS.

Materials and methods

This prospective study enrolled 121 patients (aged 58±14 years) with moderate LSS who were treated at EMMA Klinik (Seligenstadt, Germany) between February 2008 and August 2009 and followed-up at 1 (n=111), 3 (n=96), 6 (n=81) and 12 (n=52) months. Patients were treated with the Superion Interspinous Spacer, a minimally invasive spinal implant that limits back extension at the symptomatic level. Study outcomes included back function with Oswestry Disability Index, axial and extremity pain severity with a visual analog scale, health related quality of life with Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36, and adverse events.

Results

Back function rapidly improved from pretreatment (60.2±7.9%) to 1 month (33.6±10.3%) with continued improvement through to 12 months (21.0±13.7%), a 64% overall improvement (p<0.001) (Abstract O-010 figure 1A). Back function clinical success, defined as improvement of 30% or more from pretreatment values, was 92% at 12 months. Axial pain decreased at the 1 month visit (6.9±1.1 to 3.9±1.2) and this improvement was maintained through to 12 months (3.4±1.5), representing a 49% improvement (p<0.001). Similar improvements (53% overall, p<0.001) in extremity pain were observed (pretreatment: 6.6±1.4, 1 month: 3.3±1.4, 12 months: 2.8±1.5) (Abstract O-010 figure 1A). Clinical success at 12 months using a 30% improvement criterion was 76% for axial pain and 86% for extremity pain. Health related quality of life improved 41% for PCS (26.9±4.5 at pretreatment to 39.2±6.1 at 12 months) and 22% for MCS (36.0±4.2 at pretreatment to 44.0±5.7 at 12 months) (both p<0.001) (Abstract O-010 figure 1B). PCS clinical success (≥5.7 point improvement) was 81% and MCS clinical success (≥6.3 point improvement) was 62% at 12 months. Four (3.3%) explants were performed although three were unrelated to the device. Eight procedure related adverse events, observed in six (5.0%) patients, included superficial incision seroma (n=5), minor wound pain (n=2) and infection (n=1).

Abstract O-010 Figure 1

Conclusion

The Superion Interspinous Spacer is an effective and safe treatment option for patients with moderate LSS who are unresponsive to conservative care.
O-015 CLARITY Study: comparison of clinical results in GDC and matrix groups
Authors: Cognard C
Published: December 2010

Purpose

To evaluate the clinical results of the endovascular treatment of ruptured intracranial aneurysms using GDC and matrix coils.

Materials and methods

A prospective, multicenter registry was conducted in France from October 2006 to June 2007 in 19 neurointerventional centers to compare the endovascular treatment of ruptured aneurysms with GDC and matrix coils. 405 patients were treated with GDC coils and 377 with matrix coils.

Results

Endovascular treatment failed in 3/405 cases (0.7%) in the GDC group and in 2/377 cases (0.5%) in the matrix group. Adverse events related to the treatment were encountered in 71/405 patients (17.5%) in the GDC group and in 68/377 patients (18.0%) in the matrix group. Thromboembolic events were encountered in 54/405 patients (13.3%) in the GDC group and in 45/377 patients (11.9%) in the matrix group, intraoperative rupture in 15/405 patients (3.7%) in the GDC group and in 19/377 patients (5.0%) in the matrix group and early rebleeding in 2/405 patients (0.5%) in the GDC group and in 4/377 (1.1%) in the matrix group. Finally, morbidity and mortality to the treatment were, respectively, 4.0% (16/405) and 1.5% (6/405) in the GDC group and 4.0% (15/377) and 1.3% (5/377) in the matrix group.

Conclusion

The CLARITY study demonstrates that the immediate safety of the endovascular treatment of ruptured intracranial aneurysms using GDC and Matrix coils is similar with low morbidity and mortality with both types of coils.
O-016 Immediate anatomical results after the endovascular treatment of ruptured intracranial aneurysms: comparison of results with GDC and matrix coils in CLARITY series
Authors: Cognard C
Published: December 2010

Purpose

To compare the quality of immediate anatomical results after the endovascular treatment of ruptured aneurysms using GDC and matrix coils in CLARITY series.

Methods

Postoperative anatomical results were evaluated on digital subtraction angiography, anonymously and independently by two experienced neuroradiologists. Two different scales were used: the Montreal scale and a new scale specifically designed for the present study (CLARITY scale).

Results

401 aneurysms were treated using GDC coils and 373 using matrix coils. Immediate anatomical results (Montreal scale) were not significantly different with GDC or matrix coils. In the GDC group, the result was complete occlusion for 197 aneurysms (49.1%), neck remnant for 155 aneurysms (38.7%) and aneurysm remnant for 49 aneurysms (12.2%). In the matrix group, the result was complete occlusion for 168 aneurysms (44.9%), neck remnant for 171 aneurysms (45.7%) and aneurysm remnant for 35 aneurysms (9.4%). Similar results were obtained using the CLARITY scale.

The factors affecting the quality of aneurismal occlusion have been studied in both the GDC and matrix groups.

Conclusions

The postoperative occlusion after endovascular treatment of ruptured aneurysms is satisfying with a high percentage of complete occlusion or neck remnant in both the GDC (87.8%) and matrix (90.6%) groups.
O-017 Effect of biomechanical environment in vessel wall on stent restenosis
Authors: Terao M , Shobayashi Y , Goto S , Tateshima S , Sudo R , Tanishita K
Published: December 2010

Introduction

Stenting has become a standard procedure to treat atherosclerotic vessels. However, restenosis is reported in approximately one-third of patients treated with intracranial stenting, and its avoidance is drawing attention. The cause of restenosis includes vessel injury due to pressure from stent expansion and neointimal thickening due to decrease in vessel wall shear stress (WSS). Although the severity of vessel injury is proportional to neointimal thickness and restenosis, they are discussed separately. The object of this research is to examine the stress concentration and wall shear stress by a numerical analysis and reveal their configuration dependent relationship and effect to stent structure.

Materials and methods

A commercial open cell coronary stent model was used in this research to make a comparison with other research. Firstly, stent expansion in an intact vessel was simulated by the finite element method and the stress distribution of stented vessel was analyzed. Next, computational fluid dynamics was conducted to examine blood flow and WSS distribution. Furthermore, stent structure was modified to improve stress concentration and WSS. Stress concentration was avoided by connecting adjacent stent struts and making a closed cell model. This model was named model 1. In contrast, low WSS was avoided by reducing the number of stent struts in the longitudinal direction, named model 2. Vessel stress and WSS distribution was examined to look into the effect of stent structure on vessel stress and WSS.

Results and discussion

Von Mises stress and WSS distribution of stented arterial lumen is shown in Abstract O-017 figure 1. Localized radial stress and low WSS, below 1 Pa, was observed around intersections of stent struts after stent expansion. Since endothelial cells and internal elastic lamina within the vessel is deformed in the same area, vessel injury is implied. Moreover, decrease in WSS and hoop stress was observed throughout the stented vessel lumen. Like WSS, hoop stress promotes neointimal thickening. Therefore, restenosis is assumed due to the interaction of vessel injury and neointimal thickening. Also, the modified model 1 moderated stress concentration but induced low WSS. On the other hand, model 2 improved low WSS in the vessel lumen but stress concentration was observed. It is presumed that stress concentration improves when the contact area of the stent strut increases whereas the area subjected to low WSS increases with the addition of contact area of stent struts. Therefore, a stent design with connected and reduced stent struts is feasible to avoid restenosis.

Abstract O-017 Figure 1
O-020 Preliminary experience with a novel neck bridge device for bifurcation aneurysm treatment
Authors: Tateshima S , Turk A
Published: December 2010

Background

Endovascular stenting for wide necked aneurysms has become common practice since the release of the Neuroform and more recently the Enterprise stent systems. However, intrinsic to their design, these devices are indicated for the treatment of side wall aneurysm morphologies. We present a novel neck bridge device that recently received HUD approval that simulates a stent for the treatment of bifurcation aneurysms.

Methods

This novel neck bridge device composed of several nitinol wires formed to create a virtual saddle shape that covers the ostium of a bifurcation or terminal configuration aneurysm. The device is designed to deliver through a 0.021″ microcatheter and is resheathable/recaptureable up until detachment so it can be used temporarily or detached and left permanently. Multiple human basilar wide necked aneurysms were mechanically simulated in a silicone benchtop model. The device was deployed across the aneurysm ostium and detached. Then an SL-10 microcatheter was advanced across the neck bridge device and into the aneurysm, and aneurysm coiling performed using standard techniques. Next, these same steps were repeated in two experimentally created bifurcation aneurysms in canines. These animals were then survived for 60 days and explanted. Further animal work is currently underway and those results will be presented if available.

Results

The saddle neck bridge device was able to be successfully and easily deployed across the aneurysm neck in all instances. All aneurysms were able to be catheterized and coiled without difficulty. In no instance was there prolapse of coil loops through or around the device. Histologic evaluation demonstrated neoendothelial growth over the device struts without evidence of overt or abnormal inflammation or vessel trauma.

Conclusion

The saddle neck bridge device is a novel endovascular stent like device that is designed to treat bifurcation aneurysms. Preliminary benchtop and animal modeling demonstrate the device to be safe and feasible for bifurcation aneurysm treatment. It is likely that this device in combination with coils will allow treatment of many aneurysms not treatable by coils alone.

Abstract O-020 Figure 1
O-021 Significant improvement in patient functional outcome after revascularization of the middle cerebral artery by mechanical thrombectomy
Authors: Frei D , Bellon R , Kulcsar Z , Bonvin C , Rufenacht D , Alfke K , Stingele R , Jansen O , Madison M , Struffert T , Dörfler A , Grunwald I , Reith W , Haass A , Hsu D , Tarr R
Published: December 2010

Purpose

The extent to which acute ischemic stroke patients' functional outcome can be improved by mechanical thrombectomy remains controversial. This is due in part to the lack of appropriate control groups in trials with these devices. The purpose of this study was to assess the effect of the novel mechanical thrombectomy device, the Penumbra System, on patient 90 day outcome and compare the results with an appropriate control group from peer reviewed literature.

Methods and materials

This study was a retrospective case review of 89 consecutive patients at seven international centers with occlusion of the middle cerebral artery (MCA) who were treated with the Penumbra System. All patients reviewed presented to the hospital within 8 h of symptom onset with a treatable MCA occlusion (TIMI 0 or 1). The primary end point was good functional outcome, as defined by a modified Rankin Scale (mRS) score of 2 or less at 90 days postprocedure. Published results from the placebo patients in the PROACT II trial were used as the historical control.

Results

Mean baseline values at enrollment were: age 66 years, median National Institutes of Health Stroke Scale (NIHSS) score 15 (range 5–25), 51% were females and the median time from symptom onset to arterial puncture was 4.5 h. After use of the Penumbra System, 88% of the treated vessels were revascularized to TIMI 2 or 3. At discharge, 37% of patients had an NIHSS score of 0–1 or an improvement of at least 10 points. Six procedural serious adverse effects were reported in 89 patients (7%). There were a total of five (6%) symptomatic intracerebral haemorrhages reported at 24 h. At 90 days, all cause mortality was 15%. Of the 70 patients who either died or reached the 90 day follow-up, 36 (51%) had mRS scores of ≥2. Abstract O-021 table 1 shows the comparisons with the placebo patients from the PROACT II trial (JAMA1999;282:2003–11).

Abstract O-021 Table 1

Comparisons with the placebo patients from the PROACT II trial

PROACT II placebo (n=59)Penumbra MCA group (n=89)p Values*Age (years) (mean)64660.4097Female (%)39510.1814Baseline NIHSS (median (range))17 (4–28)15 (5–25)NATIMI 2–318%88%<0.0001Symptomatic ICH2%6%0.4026mRS< at 90 days25%51%0.0037Death at 90 days27%15%0.0895*

p value is for testing against PROACT II placebo using a two tailed Fisher's exact test.

ICH, intracerebral hemorrhage; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale.

Conclusions

These results suggest that when an appropriate group is used as the control, successful revascularization by the Penumbra System is associated with better functional outcome and survival.
O-023 Asymptomatic intracranial hemorrhage after endovascular therapy for acute ischemic stroke is associated with worse outcomes
Authors: Gupta R , Nogueira R , Jovin T , Levy E , Rai A , Liebeskind D , Hsu D , Rymer M , Zaidat O , Tayal A , Lin R , Natarajan S , Nanda A , Hirsch J , Abou-Chebl A , Kalia J , Nguyen T , Chen M , Yoo A
Published: December 2010

Background and purpose

The use of endovascular techniques to treat large artery occlusion in acute ischemic stroke has become more frequently employed as a treatment option. We sought to determine the predictors of intracranial hemorrhage after these procedures were performed.

Methods

This is a retrospective review of data from 13 high volume stroke centers that perform endovascular treatments for acute ischemic stroke. Patients with anterior circulation strokes treated under 8 h from symptom onset with endovascular therapy were included. Hemorrhages were classified as parenchymal hematoma (PH) types 1 and 2 and hemorrhagic infarction (HI) types 1 and 2. Patients with PH bleeds were considered symptomatic and HI bleeds were asymptomatic. Binary logistic regression modeling was performed to determine the variables associated with symptomatic and asymptomatic hemorrhages after correcting for multiple comparisons.

Results

A total of 1122 patients met the inclusion criterion for this study. Mean age for the cohort was 67±15 years with a median National Institutes of Health Stroke Scale (NIHSS) of 17 (IQR 13–20). The distribution for thrombus location at the initiation of endovascular therapy was as follows: M1 segment of the middle cerebral artery (MCA) 561 (50%), carotid terminus 214 (19%), M2 MCA 171 (15%), tandem occlusions 141 (13%) and isolated extracranial internal carotid artery occlusion 35 (3%). Parenchymal hematomas occurred in 96 (8.5%) patients and HI in 265 (24%) patients. There were no variables associated with symptomatic hemorrhages while the following variables were predictors of asymptomatic hemorrhage: diabetes mellitus (OR 2.02; 95% CI 1.46 to 2.79; p<0.0001), preprocedural use of intravenous tissue plasminogen activator (tPA) (OR 1.61, 95% CI 1.17 to 2.21; p<0.003), intra-arterial thrombolytic infusion (OR 1.52, 95% CI 1.09 to 2.10; p<0.01), higher baseline NIHSS (OR 1.032, 95% CI 1.001 to 1.06; p<0.04) and use of the Merci device (OR 1.71, 95% CI 1.18 to 2.48; p<0.003). After controlling for age, baseline NIHSS, recanalization status, PH, type of sedation and site of occlusion, the presence of asymptomatic hemorrhage was associated with a poor clinical outcome (OR 2.23, 1.53 to 3.23; p<0.0001).

Conclusions

Diabetic patients and those who have been treated with intravenous tPA prior to the procedure or intraprocedural use of thrombolytics or the Merci device appear to be at a higher risk for asymptomatic hemorrhage. Moreover, patients with asymptomatic hemorrhage appear to be at a higher risk for a worse clinical outcome at the 90 day follow-up.
O-003 Prediction of periprocedual ischemic complication in carotid artery stenting with filter embolic protection device: feasibility of MR plaque imaging
Authors: Takayama K , Nakagawa H , Taoka T , Miyouchin K , Wada T , Sakamoto M , Miyasaka T , Akashi T , Kichikawa K , Kurokawa S
Published: December 2010

Purpose

Our purpose is to investigate the feasibility of MR plaque imaging to predict the high risk lesion for ischemic complication during carotid artery stenting (CAS) using a filter embolic protection device (EPD).

Methods

100 carotid artery stenotic lesions in 96 patients before CAS (89 men and seven women; median age 72.2 years) were evaluated by MR plaque imaging with black blood T1 weighted images. The population consisted of 52% symptomatic stenosis, more than 50% at the common or internal carotid artery, and 48% asymptomatic stenosis more than 80% stenosis. All CAS procedures were performed by standard procedure using filter EPD (Angioguard XP). Main plaque components were classified into unstable plaque (intraplaque hemorrhage and lipid rich/necrotic core) and stable (fibrous tissue and dense calcification) from the signal pattern. Development of new ischemic lesions on diffusion weighted imaging was assessed within 48 h after CAS. We made statistical assessment on the plaque classification and the number of new ischemic lesions.

Results

Technical success with the CAS procedures was achieved in 100 (100%) procedures. Ipsilateral new ischemic lesions were observed in 34 CAS procedures (34.0%). Ipsilateral multiple ischemic lesions (>10) were observed in seven CAS procedures (7%). In seven patients with multiple ischemic lesions, four showed minor strokes, two showed a transient ischemic attack and one was asymtopmatic. New ischemic lesions except multiple ischemic lesions were all asymtopmatic. There was no significant difference between unstable and stable plaques for the presence of new ischemic lesion. However, multiple ischemic lesions occurred significantly (p<0.01) more frequently in patients with unstable plaque.

Conclusions

Presence of unstable carotid plaques showed a higher risk of ischemic complication of CAS with filter EPD than stable plaques.
O-031 Hyperacute cortical neuroplasticity following preoperative embolization of brain AVMs
Authors: Eesa M , Festa J , Lazar R , Meyers P
Published: December 2010

Purpose

Cerebral arteriovenous malformations (AVM) occur due to abnormal vascular morphogenesis, and reorganization of neurological function has been well documented in patients harboring them. Patients undergoing endovascular treatment for nidal reduction of brain AVMs prior to surgical resection may develop transitory neurological symptoms which may represent a manifestation of such a response occurring in a hyperacute fashion. The purpose of this study was to demonstrate any functional MRI (fMRI) evidence for hyperacute neuroplasticity in patients with brain AVMs undergoing pre-operative embolization.

Materials and methods

12 patients (aged 24–55 years; mean 38±7.6 years; nine men, 10 right-handed) with cerebral AVMs who underwent preoperative embolization at our center from 2004 to 2008 and elected to participate were included in the study. All patients had baseline MRI studies performed on 1.5 or 3 T GE Magnet which included blood oxygen level dependant (BOLD) fMRI studies using multiple motor, visual and language paradigm(s). Patients were pretreated with anticonvulsants and maintained therapeutic levels. Patients then underwent diagnostic catheter angiograms, superselective arteriography and provocative testing (WADA) prior to the embolization in the same procedure. Patients were then taken for repeat fMRI studies within 1–2 h. Pre and post-embolization fMRI data were evaluated by readers who were blinded to the patient data. The BOLD fMRI data was coregistered onto the structural images and categorized as no reorganization or definite reorganization of neurological function.

Results

A total of 12 eloquent region AVMs were treated in 12 patients. There were two grade II and 10 grade III AVMs. All patients underwent an embolization procedure as per the institutional protocol with the aim of nidal penetration and maximal nidal reduction using n-butyl cyanoacrylate (Trufil NBCA: Cordis Neurovascular, Raynam, Massachusetts, USA). There were no major (stroke or death) or minor complications. One patient developed a transient neurological deficit (aphasia) immediately following endovascular treatment and was shown to have relocated language function without diffusion weighted infarction. There were no hemorrhagic complications.

Conclusions

Hyperacute neuroplasticity may be demonstrated in patients with cerebral AVMs undergoing preoperative embolization and occlusion. This may explain some of the transient neurological deficits that are not uncommonly seen in such patients. Improved characterization of this neuroplastic response may be useful in the treatment planning of AVM patients and rehabilitative care of acute stroke patients.

Abstract O-031 Figure 1
O-008 Long term angiographic follow-up of intracranial dural arteriovenous fistulas treated with Onyx embolization: consecutive series of 37 patients
Authors: Nogueira R , Rabinov J , Dabus G , Yoo A , Ogilvy C , Hirsch J , Pryor J
Published: December 2010

Background

Onyx is a non-adhesive liquid embolic agent that has gained wide acceptance in the treatment of intracranial pial AVMs. However, only a few series have addressed the results of Onyx embolization for the treatment of dural arteriovenous fistulas (DAVFs). We now report on the long term results of Onyx treatment for intracranial DAVFs.

Methods

We performed a retrospective analysis of 37 consecutive patients with intracranial DAVFs (a total of 39 lesions) who were treated with Onyx as the single treatment modality between March 2006 and April 2009. A trans-arterial approach was employed in all cases, and Onyx-18 or a combination of Onyx-18/Onyx-34 was used to embolize the DAVF. Patients underwent control angiography at 3 months and 12 months post-embolization to assess for recurrent or residual shunting.

Results

Mean age of these 37 patients was 56±11 years (median 56, range 30–76). There were 22 men and 15 women. 11 lesions (29.7%) were classified as Cognard IV/Borden 3; 14 lesions (37.8%) as Cognard III/Borden 3; four lesions (10.8%) as Cognard IIa + IIb/Borden 2; three lesions (8.1%) as Cognard IIb/Borden 2; one lesion (2.7%) as Cognard IIa/Borden 1; and four lesions (10.8%) as Cognard I/Borden 1. A total of 46 procedures were performed (three procedures in three patients; two in three patients; and one in 31 patients). Complete angiographic cure on immediate post-treatment angiography was achieved in 35 patients. One patient underwent surgical resection after partial embolization. The remaining patient had a residual fistula involving the jugular fossa below the skull base without evidence of any residual intracranial component. Complications included one asymptomatic extracranial vertebral artery dissection and two facial palsies. There was no other significant morbidity or mortality. Follow-up angiography is currently available in 34 patients. There was no evidence of residual or recurrent DAVF in 33 patients. One of the initially “cured” patients had evidence of a small recurrent DAVF on short-term follow-up. This was attributed to lack of penetration of the embolic agent into the proximal venous compartment. This patient was asymptomatic and was subsequently embolized with Onyx resulting in stable cure on follow-up angiogram performed 11 months later. Twenty-one patients have long term (>1 year) follow-up; 19 of these had follow-up angiography at both 3 and 12 months. In all these 19 cases, the angiographic results were stable across the two time epochs.

Conclusion

In our experience, the endovascular treatment of intracranial DAVFs with Onyx is safe and highly effective with no evidence of any significant recurrence in the long term follow-up. A single angiography at 3–6 months appears to be reasonable in the follow-up of these patients.
E-015 Onyx embolization of facial arteriovenous malformations
Authors: Chaudry I , Turner R , Turk A
Published: December 2010

Introduction

Vascular malformations of the head and neck encompass a wide range of lesions, including lymphatic malformations, hemangiomas, venous malformations and true arteriovenous malformations. Treatment of these lesions is challenging because of the vital structures in the region as well as the need to preserve function and aesthetics. The mainstay of treatment has been reconstructive surgery and glue embolization. Onyx is an ideal embolization material; however, its use has been limited due to concerns of tattooing the skin. We present three cases of high flow facial arteriovenous malformations effectively embolized transarterially and/or percutaneously with Onyx without complication.

Case presentation

Patient No 1 is a 22-year-old man with arteriovenous malformation of the right lower lip with a high flow fistulous component. The patient presented because of prominence of the lower lip and daily episodes of pulsatile bleeding from the lip. Patient No 2 is 16-year-old woman with a left malar arteriovenous malformation (AVM) who presented because of asymmetric prominence of her left cheek that was intermittently painful and occasional episode of epistaxis. Patient No 3 is an 11-year-old girl with a large left maxillary AVM who presented with multiple episodes of epistaxis, bleeding from her mouth after brushing her teeth and emesis consisting of swallowed blood.

Results

The three patients were successfully embolized utilizing either a transarterial or percutaneous approach with Onyx. Specifically, patient No 1 had embolization of the facial artery and lower lip AVM in two stages. There was some tattooing of the lower lip which was acceptable as it was within the planned resection field. There were no other areas of tattooing along the remainder of the lip, lateral commisure or chin. Patient No 2 had transarterial embolization of the descending palatine artery and sphenopalatine arteries with cure. No tattooing of the left check or nasolabial fold was seen. She has persistent hypertrophy of the left cheek soft tissues and is planned for reconstructive molding of the cheek. Patient No 3 had embolization of the sphenopalatine artery, descending palatine artery and facial artery as well as direct percutaneous embolization of her maxillary AVM. No tattooing of her cheek, lips, oral mucosa or gums were noted.

Conclusion

Transarterial and percutaneous embolization of facial AVMs can be safely performed with little risk of tattooing the skin or mucosal surfaces.
E-016 Enterprise stent assisted coil embolization of cerebral aneurysms
Authors: Afshani M , Hoit D , Morris S , Barr J , Arthur A
Published: December 2010

Introduction

Cerebral aneurysms have morphometric features that influence the initial and long term success of coil embolization. Advances in coil assist technology now permit endovascular treatment of previously uncoilable aneurysms. We report a single institution experience of 52 patients with intracranial aneurysms that necessitated stent adjunctive treatment for occlusion, with angiographic follow-up studies available on 46 of the 52 patients.

Methods

Between May 2007 and November 2009, 52 patients with 55 intracranial aneurysms were treated by Enterprise stent mediated coil embolization. Initial and short term demographic, clinical and radiographic outcome data were collected and analyzed for technical success of the initial intervention, clinical complication rates, 6 month occlusion and recannalization rates, and delayed radiographic complications.

Results

Seven aneurysms in seven patients were re-treatments of previously coiled aneurysms. 48 aneurysms in 45 patients were stent coiled as an initial treatment. 13 were treated after an acute subarachnoid hemorrhage. Initial procedural results showed complete occlusion (Raymond I) in 14/55 (25%), neck remnant (Raymond II) in 12/55 (22%) and incomplete occlusion (Raymond III) in 29/55(53%). Periprocedural complications were infrequent, with no aneurysm perforations, and one thromboembolic event resulting in an anterior cerebral artery stroke. Stent migration was the most frequent technical complication occurring in four cases. Six month follow-up arteriography was available for 46 patients with 48 aneurysms. Complete occlusion was present in 28/48 (58%) aneurysms, neck remnant or regrowth was present in 12/48 (25%) and 8/48 (17%) were incompletely treated. Five patients with five aneurysms eventually underwent further embolization, and delayed placement of a second enterprise stent was necessary in one patient. In-stent stenosis was an infrequent problem occurring in 4/48 (8%), none of which were hemodynamically significant. One patient developed a mild stenosis in a perforating vessel adjacent to the stent.

Conclusion

The Enterprise stent is a safe and useful device in treating wide necked cerebral aneurysms. Our short term experience demonstrates a low rate of complications and a trend toward progressive occlusion among patients who initially had a neck or dome remnant.
E-017 Emergency Onyx embolization of avulsed basilar artery perforator following an endoscopic colloid cyst resection
Authors: Turner R , Lena J , Chaudry I , Turk A
Published: December 2010

Introduction

Endoscopic resection of a colloid cyst and third ventriculostomy is a well described neurosurgical procedure and is performed commonly. Inadvertent vascular injury can occur due to the limited peripheral field of view offered by the endoscope. We present a case of colloid cyst resection and third ventriculostomy where neurological decline occurred during anesthesia emergence and imaging demonstrated active basilar perforator extravasation on CT angiography (CTA) which was treated with emergency embolization.

Case presentation

A 23-year-old man presented with headaches. He was found to have hydrocephalus due to a third ventricular colloid cyst. The patient underwent endoscopic resection and third ventriculostomy. During emergence, the patient was found to have a dilated right pupil. A ventriculostomy drain was placed and the patient underwent emergent CT/CTA which demonstrated intraventricular and pre-pontine hemorrhage with active extravasation. The patient underwent emergency angiography which demonstrated active contrast extravasation from a right P1 thalamoperforator. The vessel was catheterized and embolized with Onyx (eV3, Plymouth, Minnesota, USA) (Abstract E-017 figure 1).

Abstract E-017 Figure 1

Results

There was immediate cessation of extravasation. The patient recovered and was following commands and getting out of bed. He had a complicated clinical course and subsequently developed meningitis and infarcts of his right middle cerebral artery territory and left basal ganglia from vasospasm. His prolonged hospital course concluded and the patient was discharged to home.

Conclusion

Vascular injury is a rare but devastating complication of intracranial surgery. This is a unique case where emergent endovascular surgery immediately yielded an optimal angiographic result and provided the patient the best opportunity for recovery.
E-031 070 Neuron conduit technique for intracranial delivery and deployment of 6 mm and 8 mm carotid stents in the setting of proximal vessel tortuosity
Authors: Turner R , Chaudry I , Turk A
Published: December 2010

Introduction

Endovascular stenting is a common treatment modality for intravascular stenosis. Current intracranial devices are relatively atraumatic and flexible to allow for navigation through tortuous anatomy such as the carotid siphon to reach its intended target. At times, large vessel diameters preclude the use of intracranial stents. Larger carotid or wall stents are limited in their ability to navigate tortuous anatomy due to their stiffness. We present two cases where vessel size demanded a larger stent but vascular tortuosity prevented primary navigation to the target lesion.

Case presentation

The first patient was found to have symptomatic sagittal sinus stenosis with venous outflow obstruction due to compression from a posterior interhemispheric fissure meningioma. She presented with blurred vision and papilledema. The second patient had symptomatic right internal carotid stenosis and stroke symptoms.

Results

In both cases, severe tortuosity was present proximal to the target location. In each case, a 070 Neuron (Alameda, California, USA) was able to navigate through the tortuosity and across the intended lesions. In the first patient, a 8 mm×40 mm Cordis Precise (Miami Lakes, Florida, USA) stent tracked through the Neuron, which was then withdrawn and the stent was successfully deployed in the superior sagittal sinus. The patient had the second stent placed using the same technique from the torcula to the right transverse sinus. In the other patient, attempts to primarily navigate through the tortuous carotid artery to reach the target location failed. The 070 Neuron was able to safely and successfully navigate through the tortuosity over an 038 glide wire and cross the target lesion. Two Cordis Precise stents (6 mm×20 mm and 5 mm×20 mm) were able to successfully navigate through the Neuron and deploy across the lesion in the internal carotid artery petrous segment. Control angiography did not demonstrate any evidence of vascular injury or stroke.

Conclusion

Severe tortuosity can preclude successful primary navigation of larger, non-intracranial stents due to stent inflexibility. Use of a flexible guide catheter can provide a conduit to deliver these devices to their intended targets successfully.
E-032 Arteriovenous malformation management via endovascular embolization: Onyx versus n-butyl cyanoacrylate
Authors: El-Gengaihy A , Dawood A , Cornett O , Prestigiacomo C , Gandhi C
Published: December 2010

Introduction

Treatment of brain arteriovenous malformations (BAVMs) is achieved by embolization, surgery, radiosurgery or any combination of these modalities. The aim of endovascular management of BAVMs before surgical resection is to minimize intraoperative blood loss, to occlude the entire BAVM or at least minimize the size of the nidus. Endovascular treatment is achieved by using n-butyl cyanoacrylate (n-BCA) or Onyx embolic agent.

Methods

14 Onyx and 15 n-BCA cases who were treated via endovascular procedures were randomly selected from 2003 to 2009 and were retrospectively analyzed. We began by comparing patient demographics, complication rates, Spetzler–Martin grading scale, BAVM volumes, pre- and post-embolization volumes, contrast loads, radiation times, as well as the number of feeder arteries. Volume of the nidus was calculated after three angiographic diameters of the lesion were obtained. The horizontal and vertical diameters were obtained from the anteroposterior projection and the longitudinal diameter from the lateral projection. We considered the BAVM to take an ellipsoid shape and we used Pasqualin method in calculating the volume of the BAVM:V= (wxhxl)/2

Results

The mean pre-embolization nidal volume for Onyx and n-BCA cases were 5.59±4.84 cm3and 4.11±4.30 cm3, respectively. No significant statistical difference between Onyx and n-BCA pre-embolization volumes was observed. The mean post-embolization volume for Onyx and n-BCA were 2.68±2.72 cm3and 1.68±1.38 cm3, respectively. The per cent of obliteration of the BAVM was observed to be 71% in Onyx cases compared with n-BCA cases, which was 62.5% (p=0.2). Contrast load was observed to be higher in n-BCA cases compared with Onyx cases (p=0.8). However, fluoroscopy time was observed to be significantly higher in Onyx cases compared with n-BCA cases (P=0.0009). On the other hand, patients treated with Onyx as the sole embolic agent had fewer staged embolizations compared with n-BCA patients.

Conclusion

The purpose of our study is to report our experience in using Onyx versus n-BCA and report our anatomic and clinical results accomplished using these two forms of treatment. Both modalities of treatment are comparable with regard to percentage of obliteration of the BAVM. However, Onyx requires a fewer number of staged embolizations to achieve the same degree of obliteration as one would achieve with n-BCA.
E-033 Percutaneous cement augmentation for treatment of metastatic lesions of the spine and pelvis using a novel highly viscous cement: experience in 17 consecutive patients
Authors: Georgy B
Published: December 2010

Purpose

Percutaneous cement augmentation had been described for the treatment of the painful metastatic lesions of the spine and pelvic bones using standard vertebroplasty systems, usually with low viscosity cements, and has been associated with a higher percentage of leaks compared with benign fractures. The study was done to assess the safety, feasibility and clinical outcome of using a highly viscous cement injected using a hydrolic based device in the treatment of metastatic lesions of the spine and pelvis using fluoroscopy and CT guidance.

Material and method

A series of 17 consecutively treated patients with different types of different primary and secondary tumors were identified for the review. There were a total of 29 lesions treated. Levels treated ranged from C7 to L5, sacrum, ilium and ischium. The degree of leakage 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: discal, venous, paravetebral, epidural or SI joint. Cement leaks were assessed using both plain films and CT. Visual analog score (VAS) for pain was collected before the procedure and within 2–4 weeks after.

Results

On plain film there was no leak at 13, minimal at 9 and moderate at 2 levels. On CT there was no leak in 4, minimal at 15 and moderate at 2 levels. CT imaging identified 10 additional minimal leaks but did not identify any additional moderate or severe leaks.

VAS pain data were available pre and post-procedure for 10/17 patients. Mean VAS pain score improved 49% from a mean preoperative score of 8.2 to a mean postoperative VAS of 4.2.

Conclusions

Percutaneous cement augmentation of metastatic lesions of the spine and pelvis is feasible and safe using a high viscosity cement system. A hydrolic injection device allows more control over the injected cement into a small caliber needles. Cement augmentation results in pain relief, as measured by VAS, with a 49% decrease in pain score.
E-034 Endovascular internal trapping for ruptured dissecting vertebral artery aneurysms
Authors: Yamamoto D , Uemura A , Fujii M , Matsukawa H , Kobayashi N , Numaguchi Y , Murakata A , Shinoda M , Ishikawa R
Published: December 2010

Purpose

Ruptured dissecting vertebral artery aneurysms should be treated immediately because of the high risk of rebleeding.

The purpose of this retrospective study is to evaluate the efficacy of endovascular internal trapping by platinum coils for ruptured dissecting vertebral artery aneurysms.

Materials and methods

We retrospectively reviewed 13 cases (eight men and five women; aged 50–80 years; mean 65 years) of acutely ruptured aneurysms of the vertebral artery treated by endovascular internal trapping between April 2003 and February 2010. Endovascular trapping was done by coil embolization of the dissected arterial segment, including the aneurysm. Evaluated subjects included success of the therapy, presence of rebleeding, procedural complication and other technical issues.

Results

In all cases, endovascular internal trapping was done successfully. There was no case of rebleeding. Three cases in which perforating arteries to brainstem originated from the dissected segment had postprocedural medullary infarction. However, the neurological symptoms diminished during the follow-up period.

Conclusion

Endovascular internal trapping is an effective and feasible therapy for ruptured dissecting aneurysms of the vertebral artery in terms of prevention of rebleeding. However, there is a risk of postprocedural medullary infarction in cases of perforating arteries originating from the dissected segment.
E-039 Coil packing volume in the treatment of ruptured intracranial aneurysms and the rate of recurrence
Authors: Cornett O , El-Gengaihy A , Gandhi C , Prestigiacomo C
Published: December 2010

Introduction

The recanalization rate of cerebral aneurysms treated by coil embolization has been reported to be as high as 60%. Several characteristics have been shown to correlate with coil compaction and recanalization including: large aneurysm size, wide neck and basilar tip location. In vitro models of side wall aneurysms show that even with maximal packing such that coil herniation into the parent vessel occurs, there remains unfilled volume within the aneurysm. This raises the question of whether or not there is a minimum threshold packing density that should be achieved to prevent recanalization. Further, is there a difference in packing density when an operator is treating a ruptured versus an unruptured cerebral aneurysm?

Purpose

To compare the packing density in ruptured and unruptured cerebral aneurysms and to assess whether this impacts on the recanalization rate.

Methods

We conducted a retrospective chart review of consecutive patients who presented to University Hospital for treatment of cerebral aneurysms between September 2003 and January 2010. We included only patients that underwent coil embolization for spherical aneurysms in our analyses. We identified 43 cerebral aneurysms of which 23 were ruptured at the time of treatment. Aneurysm volume, coil volume and packing density percentage were calculated using the web based Angiocalc program based on measurements obtained during the treatment angiogram. Follow-up angiograms were obtained for all aneurysms between 3 weeks and 1 year. Aneurysm recanalization was graded using the Raymond Score (RS).

Results

We identified 43 spherical aneurysms, 20 of which were unruptured. 76% of the patients were women and mean patient age in the unruptured and ruptured groups were 52 and 51 years, respectively. Linear regression analysis identified a statistically significant correlation between aneurysm volume and coil volume for both the ruptured and unruptured aneurysms (p=0.001 and p=0.023, respectively). In the unruptured group there was a correlation between aneurysm volumes and RS at follow-up (p=0.0074) with smaller aneurysms having durable occlusion at follow-up. Coil volume correlated with RS at follow-up in the unruptured group (p=0.026). Mean packing volume in unruptured aneurysms was 15.97 mm3versus 45.7 mm3in ruptured aneurysms but there was no difference in RS between the groups at follow-up.

Conclusion

In both groups aneurysm volume was strongly related to coil volume but this did not translate to packing volume percentage. We achieved durable RS occlusion at follow-up, especially in the smaller volume aneurysms. There was a trend towards lower RS scores at follow-up with higher packing volume but this did not reach statistical significance in either group.