bluuebunny/crossref_metadata_2025 huggingface dataset:
O-026 Safety and Efficacy of Detachable Tip Microcatheter for Embolization of Brain Arteriovenous Malformation
Authors: Paramasivam S , Altschul D , Fifi J , Ortega Gutiarrez S , Berenstein A
Published: July 2014

Purpose

We describe our experience using detachable tip microcatheters in the embolization of brain arteriovenous malformations, pial arteriovenous fistulas and vein of Galen malformations. We discuss the safety and efficacy using the detachable tip microcatheter.

Methods

During a period 9 month from March 2013 through March 2014, 16 pediatric patients in 21 procedures with 39 total injections were selected for treatment with a detachable tip under an FDA compassionate use exemption, and were admitted to our department for treatment of their brain AVM using a liquid embolic agent and a detachable tip microcatheter. The ages of the patients ranged from 3 months to 18 years old.

Results

Of the 39 total injections done, in 13 Onyx 18 or Onyx 34 was used. In those, the Catheter tip detached in one case (1/13) (7.5%). In the remaining 26 catheterizations out of the total 39, n-BCA was used for embolization. In those Catheter tip detached in eleven cases (11/26) (42%). There were no cases of premature microcatheter detachment during normal vessel navigation.

Discussion

The navigability of the Apollo™ microcatheter is comparable or better to other available over the wire microcatheters. The injection of Onyx or concentrated n-BCA is well controlled and allow reflux in a controlled fashion. The withdrawal is done in a less traumatic controlled fashion with graduated pressure under fluoroscopic guidance. We believe this to result in less chance of catheter entrapment, vessel rupture and haemorrhage.

Conclusion

A detachable tip microcatheter offers an advance in the safety and effectiveness of Onyx or nBCA embolization. It permits a true circumferential occlusion, and may further permit filling a larger amount of angioarchitecture. The catheter retrieval becomes more controlled and less traumatic. Our initial experience is encouraging and more experience is needed to categorically ascertain its safety and efficacy.

Disclosures

S. Paramasivam: None. D. Altschul: None. J. Fifi: None. S. Ortega Gutiarrez: None. A. Berenstein: None.
O-003 Resolution of Cranial Neuropathies Following Treatment of Intracranial Aneurysms with the Pipeline Embolization Device
Authors: Moon K , Albuquerque F , Ducruet A , Crowley R , McDougall C
Published: July 2014

Introduction

Intracranial aneurysms, especially those of the cavernous segment of the internal carotid artery (ICA), can present with cranial nerve palsies. Few studies exist reporting the outcomes of cranial neuropathies following treatment with the Pipeline Embolization Device (PED).

Methods

A prospectively maintained endovascular database was reviewed for all patients treated with the PED after presenting with one or more cranial nerve palsies secondary to a cerebral aneurysm since May 2011. Patient charts were reviewed to report clinical and angiographic outcomes. Only patients with clinical follow-up were included in the analysis.

Results

Since FDA approval, 127 patients were treated with the PED at our institution. Twenty-two patients presented with cranial neuropathies for initial inclusion in this study. Of these, 20 patients had sufficient follow-up for analysis. Cranial neuropathies included those of CN II, III, V, and VI, with presenting symptoms of diplopia, decreased visual acuity, and facial numbness/pain. Thirteen lesions were cavernous segment ICA aneurysms, whereas the remainder included supraclinoid and petrous segment ICA, posterior communicating artery and basilar trunk aneurysms. At a mean follow-up of 9.55 months, 15 patients (75%) had resolution or significant improvement of their cranial neuropathies and 5 had stable symptoms. Twelve (66.7%) of 18 patients with angiographic follow-up demonstrated complete obliteration or small neck residual, whereas 6 (30.0%) had residual lesion. Patients with complete/near-complete obliteration were significantly more likely to demonstrate symptomatic improvement at follow-up (p = 0.009). Two patients with persistent symptoms were eventually treated with microsurgical bypass. Complications in this series included six (30.0%) transient extracranial haemorrhagic complications related to antiplatelet therapy, and one delayed asymptomatic ICA occlusion following retreatment.

Conclusion

Treatment of intracranial aneurysms presenting with one or more cranial nerve palsies results in a high rate of clinical improvement after treatment with the PED. Clinical outcomes must be weighed against the risks and challenges faced with flow diverters.

Disclosures

K. Moon: None. F. Albuquerque: None. A. Ducruet: None. R. Crowley: None. C. McDougall: None.
O-030 Preliminary French Registry Clinical Experience with the Barrel Bifurcation Vascular Reconstruction Device
Authors: Piotin M , Blanc R , Berge J , Turjman F
Published: July 2014

Background/purpose

Endovascular Stent-assisted coiling is a well establish technique for treatment of wide-necked intracranial aneurysms. However, it remains a challenge to successfully treat complex wide-necked bifurcate aneurysms by using a single-stent and double (X and Y) stenting introduce other procedural variables. The purpose of the French Barrel™ Prospective Registry, an intention to treat study, is to investigate a single stent technique utilizing a novel fully retrievable barrel-shaped vascular reconstruction device for wide-necked bifurcate aneurysm stent assisted coiling treatment.

Methods

8 patients were enrolled within the French Barrel Registry thus far. This is a review of initial cases performed at the three French centers where Barrel VRD Device (Reverse Medical Corp, Irvine, CA) was used. Elective treatment was performed between December 2013 and March 2014. In this case series, various models of Barrel VRD device were utilised as neck-bridging devices in wide-necked bifurcate aneurysms in conjunction with embolization coils. These cases included; ACoA, MCA, Carotid Terminus, and Basilar Tip aneurysms.

Results

7 patients were treated with a single Barrel VRD device, at three French sites. Patients were placed on a double anti-platelet protocol (Clopidogrel and ASA) prior to treatment. 1 patient was enrolled, but not treated due to being a low anti-platelet responder. Patients presented with wide-necked bifurcate aneurysms measuring 4.71+/-1.62 mm necks and 1.33 +/- 0.39 mm dome/neck ratios. Aneurismal parent and branching vessel diameters were 2.69 +/- 0.44 mm and 2.45 +/- 0.25 mm, respectively. Technical success was 100% (7/7), and all embolizations were deemed clinically acceptable with initial Raymond Grade-1 in 5/7 (71%), Grade-2 in 1/7 (14%), and Grade-3 in 1/7 (14%) post-procedure. In all cases, the Barrel devices were easily positioned, via a 021 microcatheter, and offered both trans-cell or “jailed” coil microcatheter placement, good neck bridging and coil mass support, and fairly rapid detachment. As the device is resheathable, it could be placed into either branching bifurcation vessel, depending on which vessel position offered better neck coverage. No procedural Barrel device migration or coil loop protrusion was noted. Additionally, the device could be manipulatedin situto further optimise neck coverage. Discharge mRS was 0 for all patients. AE’s included 2 groin hematomas, and 1 aneurysm coil perforation, related to the procedure, not the Barrel device.

Conclusions

The initial French Barrel Registry results demonstrate that the Barrel VRD device is new tool for the endovascular treatment of wide neck bifurcate type aneurysms.

Disclosures

M. Piotin: 2; C; Covidien, Stryker, Balt, MicroVention, Reverse Medical, Neuravi, Penumbra. R. Bpanc: 2; C; Covidien, Stryker, Balt, MicroVention, Reverse Medical, Neuravi, Penumbra. J. Berge: None. F. Turjman: None.
O-034 Carotid Artery Angioplasty versus Stenting in Acute Ischemic Stroke
Authors: Choudhri O , Gupta M , Feroze A , Albers G , Lansberg M , Do H , Dodd R , Marcellus M , Marks M
Published: July 2014

Introduction

Acute ischemic stroke secondary to cervical carotid artery occlusion can lead to significant morbidity and mortality. Acute carotid occlusion may be managed by carotid angioplasty, stenting, or both. The use of carotid stents requires patients to be placed on dual antiplatelet agents, which may contribute to increased haemorrhage risk. We undertook this study to evaluate outcomes for angioplasty alone versus stenting in the setting of acute carotid occlusion.

Methods

All patients treated from 2008 to 2013 with acute cervical internal carotid artery occlusions that had intervention within eight hours of symptom onset were included. NIHSS were recorded preceding intervention, and clinical outcomes were assessed using mRS at 90 days. All imaging and angiographic data were reviewed for pre-procedural ASPECT scores, pre- and post- TICI reperfusion scores, and intracranial haemorrhage as defined by PH grading score for haemorrhage. Demographic and treatment factors were correlated with good functional outcome (mRS < 2 at 90 days and a comparison was made for patients undergoing angioplasty alone versus stenting. All patients who underwent carotid stent were placed on dual antiplatelet agents while angioplasty patients received aspirin only.

Results

Twenty-four patients (15 males, 9 females; mean age, 67 years) satisfied the inclusion criteria. Seventeen patients underwent placement of carotid stent and 7 patients had angioplasty alone. Patients in both subgroups were comparable across characteristics including comorbidities, time for onset to recanalization, ASPECTS, and IV tPA use. 35% of patients who underwent stenting had good functional outcomes, versus 71% of patients treated with angioplasty alone, although these differences were not statistically significant. No differences were seen for the two treatment groups comparing time from onset to recanalization, baseline ASPECTS, and IV tPA use. Additionally, increased age (p = 0.049) and post-treatment parenchymal haemorrhage- PH1 or PH2 (p = 0.016) correlated with poor outcomes (mRS > 2). All parenchymal haemorrhages (6/17) and deaths (5/17) fell within the stenting subgroup (35.3% and 29.4%, respectively).

Conclusions

This data suggest that patients undergoing angioplasty alone in the setting of acute internal carotid artery occlusion may have improved functional outcome at 90-day compared to those undergoing stenting. This study was limited by a small sample size and a larger study would be needed to confirm these findings.

Keywords

angioplasty, stenting, acute ischemic stroke, carotid occlusion.

Disclosures

O. Choudhri: None. M. Gupta: None. A. Feroze: None. G. Albers: None. M. Lansberg: None. H. Do: None. R. Dodd: None. M. Marcellus: None. M. Marks: None.
P-004 Radiation Dose Analysis of Large and Giant Internal Carotid Artery Aneurysm Treatment with the Pipeline Embolization Device versus Traditional Coiling Techniques
Authors: Colby G , Lin L , Nundkumar N , Jiang B , Huang J , Tamargo R , Coon A
Published: July 2014

Background

Flow diversion is an effective and increasingly accepted method for endovascular treatment of cerebral aneurysms. Additionally, the public has heightened concerns regarding radiation exposure from medical procedures. This study analyzes radiation dose and fluoroscopy time during treatment of large and giant proximal internal carotid artery (ICA) aneurysms with the pipeline embolization device (PED) versus traditional coiling techniques.

Methods

Radiation dose, fluoroscopy time, and contrast dye administration were retrospectively analyzed in 55 patients undergoing endovascular treatment of aneurysms ≥10 mm from petrous to superior hypophyseal ICA segments. Patients were treated by either PED (37 patients) or traditional coiling techniques (18 patients). Aortic arch type and proximal ICA tortuosity were also assessed as markers of access difficulty.

Results

Average radiation dose with PED treatment was 2840 ± 213 mGy and 4010 ± 708 mGy with traditional coiling techniques (p = 0.048; 29% decrease with PED). Mean fluoroscopy times for PED were 56.1 ± 5.0 min and 85.9 ± 11.9 min for coiling cases (p = 0.0087; 35% decrease with PED). These benefits existed despite more difficult arch anatomy and trend towards greater proximal vessel tortuosity in PED cases. Contrast dye amounts were also reduced by 37.5% in PED cases (75 ± 6 cc) versus coiling cases (120 ± 13 cc, p = 0.0008).

Conclusions

Treatment of large and giant proximal ICA aneurysms using PED requires less radiation, less fluoroscopy time, and less contrast administration than standard coiling techniques. This further demonstrates the benefits of flow diversion for treatment of these aneurysms.

Disclosures

G. Colby: 2; C; Covidien. L. Lin: None. N. Nundkumar: None. B. Jiang: None. J. Huang: None. R. Tamargo: None. A. Coon: 2; C; Covidien, Stryker.
P-007 Incidence and Management of Intimal Hyperplasia at 6 months after Flow Diversion for Intracranial Aneurysms
Authors: Massari F , Puri A , Hou S , Perras M , Brooks C , Stout C , Gounis M , Wakhloo A
Published: July 2014

Introduction/purpose

A new option in the treatment of large and complex intracranial aneurysms centerd along the cavernous/intradural segment of the ICA, proximal to the PCom artery, includes the utilization of flow-diverter devices. Intracranial stent/ flow diverter deployment in the treatment of aneurysm usually requires the administration of dual antiplatelet therapy for 3–12 months. Our usual protocol is to switch to mono-therapy with Aspirin after 6 months. We analyzed the results after continuing dual anti-platelet therapy based on the intimal hyperplasia (IH) noted on the 6 month follow-up cerebral angiography. The purpose of this study is to assess at 1-year follow-up the efficacy of mono or dual antiplatelet therapy in the management of in-PED IH observed at the 6-month cerebral angiogram.

Materials and methods

From October 2011 to February 2014, a total of 93 intracranial aneurysms in 83 patients (16 men and 67 women; age range, 19–85 years; mean age, 56.6 years) were treated with pipeline embolization device (PED) at our institution. A cone-beam CT (Philips, Allura Biplane FD20/20, Philips Medical, Best, Netherlands) was obtained using the angiography C-arm to assess for IH at FU angiographies. At 6-month follow-up (39 patients with 46 aneurysms) 8 cases of in-PED no-flow limiting minimal IH (< 10% vessel stenosis) were noted. In these patients medical management using continuation of dual antiplatelet therapy for additional 6 months up to a 1 year cerebral angiogram follow-up was used.

Results

In the 8 patients having IH at the 6 months angiogram, 4 patients have till now underwent a 1 year follow-up. Complete resolution of the intimal hyperplasia was seen in 3 patients, whereas a stable IH was noted in one patient. One year follow up angiography was available for an additional 11 patients, who did not have IH at the 6 month FU. The 1 year FU angiography in these patients demonstrated no interval development of IH after stopping Clopidogrel at the 6 month time period.

Conclusion

In our experience the adjustment of antiplatelet drug therapy post endovascular PED treatment of intracranial aneurysm depending on 6 month follow up findings is strongly associated with complete Pipeline Embolization Device patency at 1-year follow-up. Furthermore in our experience cone-beam CT is an accurate and precise tool in the assessment of in-PED intimal hyperplasia development during follow-up.

Disclosures

F. Massari: None. A. Puri: None. S. Hou: None. M. Perras: None. C. Brooks: None. C. Stout: None. M. Gounis: None. A. Wakhloo: None.
P-010 Optical Coherence Tomography (OCT) Before and After Flowdiverter Treatment in Basilar Dolichoectasia
Authors: Brouwer P , Ligthart J , Regar E
Published: July 2014

Optical Coherence Tomography (OCT) is an endovascular imaging modality that utilises infrared light to create high-resolution images of the vascular system. The use of OCT in cardiology is widely accepted and considered safe for imaging of the coronary artery wall, plaques and assessment of stent deployment.

In the literature to date, OCT has not been used in endovascular imaging of neurovascular pathology. In this report we describe the first case in which OCT was used to evaluate pathology and assess the quality of the flow diverter treatment both directly after the treatment and at five months follow.

The use of OCT proved to be feasible in neurovascular pathology and rendered more information than was anticipated about both morphology, underlying pathology, and treatment result at the treatment date as well as five month follow up.

Disclosures

P. Brouwer: 3; C; BALT extrusion, Paris. J. Ligthart: None. E. Regar: None.
P-013 Predicting Mass Effect Exacerbation after Pipeline Embolization of Intracranial Aneurysms
Authors: Raychev R , Tateshima S , Jahan R , Gonzalez N , Szeder V , Vinuela F , Duckwiler G
Published: July 2014

Introduction

In this study, we investigated the clinical and procedural predictors associated with interval growth manifested as new or worsened mass effect after Pipeline Embolization Device (PED) placement for treatment of intracranial aneurysms

Methods

We evaluated the baseline clinical and procedural characteristics of 46 consecutive patients who underwent 48 PED procedures. The clinical factors analyzed included age, history of smoking, history of hypertension, aneurysm size, pre-existing mass effect, platelet aggregation measured by ADP% inhibition, and administration of alternative antiplatelet treatment. Procedural factors included fluoroscopy time, adjunctive coiling, and device balloon angioplasty for optimal wall apposition. Univariate analyzes using Chi-square and T-test were conducted for categorical and continuous variables, respectively. Multivariate regression model was used to determine the strongest predictor of interval growth or worsened mass effect after PED placement. The logistic regression equation was used to determine cut off values for continuous variables included in the model.

Results

The median age was 58 (5–88), 35/46 (76%) patients were female, and the median aneurysm size was 14.5 mm (2–38 mm). PED angioplasty was performed in 21/48 (44%) procedures, and adjunctive coiling was performed in 13/48 (27%) procedures. The median fluoroscopy time was 39 (15–314) min.

15/46 (33%) of patients had pre-existing mass effect prior to PED placement, of which 3 had worsened symptoms and 2 had new mass effect after the procedure. Of the 5 patients who had new or worsened mass effect, 4 experienced complete symptomatic resolution, while 1 had a delayed aneurysm rupture requiring vessel sacrifice. 7/15 (46%) patients with pre-existing mass effect eventually experienced symptomatic improvement. Complete aneurysm occlusion rate at 6 months was 32/43 (74%).

Among all baseline clinical and procedural factors, the strongest predictor of interval growth, manifested as new or worsened mass effect, was aneurysm size larger than 18mm (OR 15.51, p = 0.018).

Conclusions

1. New or worsened mass effect after PED placement may be anticipated in patients with intracranial aneurysm exceeding 18 mm in size. Although this phenomenon is uncommon and transient in most cases, physicians should be aware as pre-procedural counselling, administration of steroids, or close follow may be warranted.

2. Overall, PED placement is an effective treatment of symptomatic mass effect from intracranial aneurysms with 46% success rate in our cohort.

Disclosures

R. Raychev: None. S. Tateshima: 2; C; Covidien; Stryker; Penumbra; Reverse Medical; Pulsar Vascular. R. Jahan: 2; C; Covidien. N. Gonzalez: None. V. Szeder: None. F. Vinuela: None. G. Duckwiler: 2; C; Sequent; Covidien; Asahi.
P-015 A New Grading System for Predicting Angiogram Negative Subarachnoid Haemorrhage
Authors: Darie I , Rayan T , Amin-Hanjani S , Du X , Aletich V , Charbel F , Alaraj A
Published: July 2014

Introduction

Angiogram negative subarachnoid haemorrhage (AN-SAH) account for about 15% of all non-traumatic SAH cases. In this paper we developed a new CT based grading system for distinguishing AN-SAH vs. aneurysmal SAH (a-SAH).

Methods

A new CT grading classification was developed based on the Hijdra system. Patterns of SAH in 13 cisterns were scored between 0–2 depending on the amount of haemorrhage (0 = No blood; 1 = partial; 2 = full). The patterns of blood in the interpeduncular, pre-pontine and pre-medullary cisterns were scored in one category: P score (range 0–6); the total amount of blood in the entire 13 cisterns was scored under T score (range 0–26). Initial CT scans from 148 consecutive AN-SAH and 180 a-SAH patients were reviewed and scored by two independent blinded neurosurgeons. Patients with pure cortical or traumatic SAH or those with CT scan performed >72 h after the SAH ictus were excluded. All performed angiograms (1st, 2ndand 3rdlook, if performed) were reviewed for presence of aneurysms.

Results

In patients with CT scan scores between P0-1;T > 9, the performed angiograms were positive in 92% (23 a-SAH vs. 2 AN-SAH), whereas in those scoring P0-1;T < 10 angiography revealed a much higher incidence of positive findings (52% a-SAH vs. 48% AN-SAH, p = 0.33). For Px; T < x+8 (xbetween 2–6), the angiograms were negative in 94.6% of cases (3 a-SAH vs. 53 AN-SAH), and in a subset of this category (P4-6; T < 14) the angiograms were negative in 100% of cases (n = 34). For patients scoring (P0-1; T < 10) and Px; T > x+7(xbetween 2–6) the scores were not predictive of angiogram results (65% a-SAH vs. AN-SAH 35%).

Conclusion

The new CT scan scoring provides an estimate for the likelihood of a negative angiogram in patients with SAH. Significant blood in the pre-brainstem cisterns with minimal or modest blood in the remaining cisterns best predicts absence of aneurysm or vascular lesion on initial and follow-up angiography.

Disclosures

I. Darie: None. T. Rayan: None. S. Amin-Hanjani: None. X. Du: None. V. Aletich: None. F. Charbel: None. A. Alaraj: None.
P-021 TREVO Stent-Retriever Acute Stroke (TRACK) Post-marketing Registry: Interim Revascularization and Clinical Outcome Results Compared to TREVO-2 and NASA Registry
Authors: Zaidat O , Castonguay A , Veznedaroglu E , Binning M , Alshekhlee A , Abraham M , Mehta S , El Khoury R , Majjhoo A , Lin E , Kabbani M , Froehler M , Nguyen T
Published: July 2014

Background

Although industry sponsored trials for newer mechanical thrombectomy devices for treatment of acute ischemic stroke (AIS) are promising, limited post-marketing data exist on the use of the TREVO device in every day clinical practice.

Objective

The ongoing TREVO Stent-Retriever Acute Stroke (TRACK) Registry aimed to assess the real-world safety, angiographic, and clinical efficacy of the TREVO device in comparison to the results from the TREVO-2 clinical trial and post-marketing North American SOLITAIRE Stent-Retriever Acute (NASA) Stroke Registry.

Design/methods

The TRACK Registry recruited clinical sites within the USA. Demographic, clinical, angiographic, and outcome data on patients treated with the TREVO device were collected. Symptomatic intracranial haemorrhage (sICH) was defined as any parenchymal hematoma, SAH, or IVH associated with a worsening of the NIHSS score by ≥4 within 24 h. The primary outcome was achieving TICI ≥2a revascularization. Secondary outcomes were mRS at 3 months, mortality, and sICH.

Results

12 centers contributed data on 93 patients for this interim analysis. Baseline demographics were: women 61.3% (57/93), white 78.5% (73/93), mean age 64.9 ± 17.8 years, median baseline NIHSS of 17 (IQR 14–22), mean fluoroscopic time 37.5 ± 31.9 min, and a mean procedure time of 101 ± 69.1 min. The TICI ≥ 2a and TICI ≥ 2b revascularization rates were 85.6% (77/90) and 65.6% (59/90), compared to the operator reported TICI ≥ 2a rate of 85% in TREVO-2 and 87.5% in NASA, and TICI ≥ 2b rate of 72.5% in NASA.

A good outcome of mRS ≤ 2 was demonstrated in 43.0% (40/93), compared to 40% (TREVO-2) and 42% (NASA). The rate of sICH was 8.4% (7/83), compared to 4% (TREVO-2) and 9.9% NASA. 90-day mortality was 21.5% (20/93) versus 29% in TREVO-2 and 30.2% in NASA.

Conclusion

The investigator initiated post marketing TRACK Registry demonstrates that the TREVO stent-retriever performance in clinical practice is comparable to the TREVO-2 trial and post-marketing NASA Registry.

Disclosures

O. Zaidat: 1; C; Stryker Neurovascular. A. Castonguay: None. E. Veznedaroglu: None. M. Binning: None. A. Alshekhlee: None. M. Abraham: None. S. Mehta: None. R. El Khoury: None. A. Majjhoo: None. E. Lin: None. M. Kabbani: None. M. Froehler: None. T. Nguyen: None.
P-023 Transfontanelle and Transcardiac Veno-arterial Approaches for Embolization of Complex Pediatric Intra-cranial Vascular Malformations
Authors: Jagadeesan B , Zachararotos H , Shea K , Nascene D , Grande A , Tummala R
Published: July 2014

Introduction

Trans-arterial endovascular embolization using liquid embolics for the treatment of intra-cranial vascular lesions can be challenging in neonates and infants due to difficulties with arterial access. This is particularly true when repeated procedures have to be performed for staged embolization of very complex lesions. Sometimes, there can be severe intra-procedural spasm or long standing occlusion of the femoral arteries, which can render arterial access very difficult. A Transvenous approach may also not be useful due to the angio-architecture of some of these lesions. Herein, we describe two patients in whom arterial access was compromised but embolization could still be carried out via alternate techniques.

Case Series

Case 1: A 2 week old infant presented with a Dural Sinus Malformation and a giant midline venous pouch, with multiple associated high flow arteriovenous fistulae. At the end of six trans-arterial embolization sessions with femoral arterial punctures, she still had residual high flow shunting. Both femoral arteries were small in calibre and the left was occluded. Therefore, the midline venous pouch was punctured via a percutaneous transfontanelle approach (through the posterior fontanelle) and the malformation was successfully embolised using Ethylene Vinyl Alcohol Co-polymer (Onyx) and coils while preserving the superior saggital sinus.

Case 2: A 5 month old presented for elective embolization of an antenatally diagnosed mixed mural and choroidal type Vein of Galen Aneurysmal Malformation (VGAM). Both femoral arteries were small in size and developed severe vasospasm when an ultra-sound guided needle puncture was attempted precluding arterial access by this approach. Therefore, the right common femoral vein (CFV) was punctured under ultrasound and a 4 French Guiding catheter was passed through this puncture site and advanced to the right atrium. Eventually arterial access was obtained by navigating this catheter from the right atrium to the left atrium across the patent Foramen Ovale followed by advancement into the aortic arch. Embolization was then carried out successfully by the injection of Onyx or n-BCA from multiple pericallosal and choroidal arteries with approximately 50% reduction in flow through the VGAM.

Conclusion

Per-cutaneous Transfontanlle and Trans-cardiac percutaneous veno-arterial approaches for embolization may be useful in the treatment of selected intra-cranial vascular malformations in neonates and infants.

Disclosures

B. Jagadeesan: 2; C; Covidien, Microvention, Lake Regional. H. Zachararotos: None. K. Shea: None. D. Nascene: None. A. Grande: 2; C; Covidien, Integra. R. Tummala: 2; C; Lake Regional.
O-006 Analysis of Screened Patients from the Penumbra THERAPY Trial: Correlations of Clot Length Assessed by Thin-Section CT in a Sequential Series of Acute Stroke Patients
Authors: Frei D , Heck D , Yoo A , Loy D , Buell H , Kamalian S , Morais L , Bitner A , Meyer D , Kuo S , Bose A , Sit S
Published: July 2014

Purpose

Thin-section (≤2.5 mm) NCCT is a dependable method for measurement of clot length in documented anterior circulation occlusions. A majority of clots in the proximal anterior circulation are ≥8 mm, which have low probability of revascularization with IV rtPA alone. Nevertheless, past studies have had sampling restrictions, and correlations of clot length continue to be classified.

Methods

Data was captured to investigate potential correlates of clot length from an ongoing multicenter review. Patients were eligible if presented within 8 h of onset, had thin-section NCCT admission imaging, and evidence of ICA-T, M1, or M2 MCA occlusion. All patients had their occlusions documented by CTA, angiography, or MRI. Patients did not necessarily have thrombectomy performed. Baseline characteristics of interest included age, sex, baseline NIHSS, ASPECTS, occlusion level, IV rtPA dose pre vs. post scan, time from stroke onset to imaging, and IA recanalization. Univariate analyzes were implemented with clot length as a dichotomized variable (≥8 mm vs <8 mm), and multivariate logistic regression was used to define predictors.

Results

Consecutive stroke admissions were reviewed at 3 US centers between August 2011 and March 2013 for eligibility, and 175 patients met criteria. Mean age was 70 years old; 56% were female. Median baseline NIHSS score was 17 (IQR 12–22). The level of occlusion was distributed such that 23% were ICA-T, 54% M1, and 23% M2 MCA. Of the 175 confirmed occlusions, hyperdense clot was visible in 89% (156/175) of cases. Visible clot ranged from 2 mm to 65 mm, while mean length was 14 mm. There were 66% (115/175) patients with clot lengths ≥8 mm. In comparing clot length to occlusion level, 90% of ICA-T, 69% of M1, and 34% of M2 occlusions were ≥8 mm (p < 0.001), with median clot lengths of 20.5, 14.1, and 7.2, respectively. The only significant multivariate predictor of clot length was the occlusion level (OR, 95% CI =3.9 (2.2–6.9) per step from M2 to M1 to ICA-T, p < 0.0001).

Conclusion

This analysis further supports the idea of measuring hyperdense thrombus by use of thin-section NCCT. Occlusion site is a key predictor of clot length, which may explain the relative ineffectiveness of IV rtPA in more proximal anterior circulation large vessels. These findings suggest a sizeable population who may benefit from a bridging approach.

Disclosures

D. Frei: 3; C; Penumbra Inc. 4; C; Penumbra Inc. D. Heck: None. A. Yoo: 1; C; National Institutes of Health, Penumbra Inc., Remedy Pharmaceuticals. D. Loy: None. H. Buell: 5; C; Penumbra Inc. S. Kamalian: 1; C; GE Healthcare, Department of Defense, CIMIT. L. Morais: None. A. Bitner: 3; C; Penumbra Inc. D. Meyer: 5; C; Penumbra Inc. S. Kuo: 5; C; Penumbra Inc. A. Bose: 4; C; Penumbra Inc. 5; C; Penumbra Inc. S. Sit: 4; C; Penumbra Inc. 5; C; Penumbra Inc.
P-025 Interventional Treatment of High Flow Craniofacial Vascular Malformations
Authors: Dabus G , Linfante I , Lin E , Benenati J , Martínez-Galdámez M
Published: July 2014

Objective

High flow craniofacial vascular malformations are uncommon lesions that pose a very difficult therapeutic challenge. They are locally aggressive lesions that can present in several different ways from completely asymptomatic lesions to significant bleeding, pain, neuropathy, tissue destruction or congestive heart failure. Several therapeutic strategies have been proposed including surgery, embolization or a combination of both. We report our experience in the treatment of high flow craniofacial vascular malformations.

Methods

The neurointerventional databases of 2 institutions were retrospectively reviewed from October of 2010 to March of 2014. All patients with high flow craniofacial vascular malformations were included in the analysis. Clinical presentation, location, type, agent and techniques used, procedural complications, clinical and imaging follow ups were included in the analysis.

Results

Among the patients in our neurointerventional databases, 16 patients (11 females and 5 male) met the inclusion criteria in our study. Patients' ages ranged from 4 to 66 years old (mean 45.2 years). All patients were symptomatic (pain, bleeding and mass/disfigurement were the most prevalent symptoms). One patient had 2 separated arteriovenous malformations (one nasal and the other forehead/scalp). One patient with a nasal arteriovenous malformation had CM-AVM syndrome. Overall, there were 12 arteriovenous malformations and 5 arteriovenous fistuli treated in 26 embolizations procedures (ranging from 1 procedure to 4 procedures; mean 1.6 procedures). Onyx was the predominant agent used in 20 procedures. Two procedures were done using predominantly ETOH; 2 procedures were done using predominantly nBCA; and 2 procedures used only coils/particles. One procedure was performed using only transvenous route; direct puncture was the only access in 9 cases; transarterial technique was the only route in 12 procedures; and 4 procedures used combine transarterial and direct puncture techniques. In 26 procedures there was one procedural complication (skin ulceration). At the end of last treatment session 10 out of 16 patients had angiographic cure or minimal residual vascular malformation (5 AVFs and 5 AVMs). Symptomatic control was achieved in all cases with all patients stating that the symptoms had resolved or significant improvement (mean follow up 8 months). Five patients underwent scheduled surgery to remove the arteriovenous malformations.

Conclusions

In summary, high flow craniofacial vascular malformations are challenging diseases that can be successfully managed with interventional techniques providing symptomatic control.

Disclosures

G. Dabus: 2; C; Covidien, Microvention, Reverse Medical. 4; C; Surpass Medical. I. Linfante: 2; C; Covidien, Stryker, Codman. 4; C; Surpass Medical. E. Lin: None. J. Benenati: 2; C; Gore, Cook, Penumbra, Covidien, Reverse Medical, Cordis, Surefire, Abbott, Angio Dynamics, MC-10. M. Martínez-Galdámez: 2; C; Covidien.
P-031 Single Center Experience with the ADAPT Technique for Acute Ischemic Stroke
Authors: Blanc R , Fahed R , Redjem H , Bartolini B , Pistocchi S , Piotin M
Published: July 2014

Background

We report our single center experience of endovascular treatment of stroke by a technique of direct aspiration with large bore catheter.

Methods

From September 2013 to March 2014 we included prospectively on intent to treat 80 patients presenting with large vessels occlusion in the settings of acute ischemic stroke. The ADAPT technique was utilised in first intention in all patients and was associated with stentriever technique when necessary. Procedural and clinical data were collected for analysis.

Results

Patients presented with an admitting median National Institutes of Health Stroke Scale (NIHSS) score of 15 (1–26). The localization of arterial occlusion was the MCA in 40/80 (50%), the ICA in 10/80 (12.5%), a tandem occlusion in 24/80 (30%) and the vertebro basilar territory in 6/80 (7.5%). The aspiration technique alone was successful in achieving Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 43% of cases (38/80). The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 87.5%. With ADAPT alone, the average time from groin puncture to at least TICI 2b recanalization was 37 min (from clot contact to recanalization: 17 min). Ninety day functional outcomes was available for 35 patients were 50% (modified Rankin Scale (mRS) 0–2) and 15% (mRS 6). For the overall series there were 8 cases (10%) of procedural complications (one non occlusive dissection 4 distal emboli, and 5 Subarachnoid haemorrhages) and 2 symptomatic intracerebral haemorrhages (2.5%).

Discussion

The Aspiration technique utilising large bore aspiration catheters technique alone was effective in 43% of the cases being fast, safe and simple, nevertheless in our experience to achieve a recanalization rate of 87.5% it add to be completed by the use of stentrievers in the other cases. The relevance of this technique needs to studied in larger prospective multicentric studies.

Disclosures

R. Blanc: 2; C; Balt, Stryker, Covidien, Microvention, Neuravi, Penumbra. 4; C; Lazarus. R. Fahed: None. H. Redjem: 2; C; Balt, Stryker, Covidien, Microvention, Neuravi, Penumbra. B. Bartolini: 2; C; Balt, Stryker, Covidien, Microvention, Neuravi, Penumbra. S. Pistocchi: 2; C; Balt, Stryker, Covidien, Microvention, Neuravi, Penumbra. M. Piotin: 2; C; Balt, Stryker, Covidien, Microvention, Neuravi, Penumbra. 4; C; Lazarus.
E-001 TARGET Intracranial Aneurysm Coiling Prospective Multicenter Registry: Initial Periprocedural Results in 120 Patients
Authors: Zaidat O , Castonguay A , Puri A , Rai A , Badruddin A , Mack W , Alshekklee A , Shah Q , Hussain S , Kabbani M , Bulsara K , Taqi M , Janardhan V
Published: July 2014

Background and purpose

To describe the periprocedural results of the TARGET Registry, an on-going, prospective, non-randomised, multicenter, real-world study of patients with ruptured or unruptured intracranial aneurysms that are embolised with the new generation TARGET Coils. In particular, the aneurysm that were coiled with 100% 360 complex coils only were compared to the aneurysm that were coiled with mixed 360 and helical coil or helical coils only.

Methods

Patients withde novountreated ruptured or unruptured intracranial aneurysms were embolised with either TARGET 360° or Helical coils in 13 US centers. The primary outcome, aneurysm packing density (PD), was assessed at immediate post-procedure. Analysis was by per protocol. The secondary outcomes were modified Rankin’s Scale (mRS) at discharge and the influence of use of 100% 360 coils on clinical and angiographic outcomes. JMP statistical software was used for analysis.

Results

120 patients enrolled to date were eligible for this per protocol analysis. 51 (42.5%) patients with ruptured and 69 (57.5%) with unruptured aneurysms were treated. Mean age was 58.1 ± 13.04 years; 75.6% female, 73.3% white. TARGET 360° coils was used in 60.5%, mixed 360° and Helical Coils in 35.1%, and TARGET Helical Coils in 4.4% of the cases. Immediate complete occlusion rate was seen in 84.4% of the cases. Packing density was the main predictor of complete occlusion (mean PD 28.7 ± 18.1 in those with complete occlusion vs. 20 ± 12, p-value 0.005). Mean PD was 25.4 ± 16.3%. Multivariate analysis showed maximum aneurysm size (p value 0.0001), and use of stent (p value 0.02) to be independent predictors of PD. In-hospital mortality was 0.8% (1/120) and discharge good outcome (mRS 0–2) was seen in 110/120 (91.7%). Poor outcome occurred in 13.7% of the ruptured aneurysm and 4.4% of the unruptured aneurysms. Predictors of discharge outcome included age, rupture presentation, aneurysm neck size, and occlusion grade.

Conclusion

In this prospective and core lab adjudicated multicenter Target aneurysm registry, the mean PD was 25.4 ± 16.3% and was the main predictor of complete aneurysm occlusion. Poor outcome was 4.4% in the unruptured aneurysm and 13.7% in the ruptured aneurysms. Predictor of outcome at discharge included age, rupture status, aneurysm occlusion, and aneurysm neck size.

Disclosures

O. Zaidat: None. A. Castonguay: None. A. Puri: None. A. Rai: None. A. Badruddin: None. W. Mack: None. A. Alshekklee: None. Q. Shah: None. S. Hussain: None. M. Kabbani: None. K. Bulsara: None. M. Taqi: None. V. Janardhan: None.
E-003 Aneurysm Re-treatments Following Recurrences After Initial Use of the Pipeline Embolization Device
Authors: Park M , Nanaszko M , Sanborn M , Moon K , McDougall C , Albuquerque F
Published: July 2014

Introduction

Although the Pipeline Embolization Device (PED, eV3 Neurovascular, Irvine, California) has provided the field of neuro-interventional surgery with a significant leap forward in the treatment of cerebral aneurysms, treatment failures still exist with this new platform. We sought to examine our experience with re-treatments of cerebral aneurysms after initial treatment with the PED.

Materials and methods

We retrospectively examined our prospectively maintained endovascular neurosurgical database for cerebral aneurysm treatment failures using the PED from May 2011 to the present time. Nine patients (1 male, 8 female; Age range 28–83 yrs, average age 54.4 yrs, SD 17.5 yrs) treated for nine aneurysms (Average size 17.7 mm, SD 11.9 mm) out of 137 total patients treated with PED were identified during our study period (6.6% re-treatment rate, 9/137).

Results

Of the nine re-treatments, six were due to persistent filling of the aneurysm, while three were re-treated due to PED contraction/migration at an average time interval of 6.9 months (SD 3.7 months). Following the initial treatment and at the time of re-treatment, all aneurysms had a Raymond 3 occlusion. Despite this, the angiographic appearance of the aneurysms at the time of re-treatment remained the same in 2, better in 6, and worse in 1. At the last follow-up, two aneurysms had a Raymond 1 occlusion, three aneurysms had a Raymond 2 occlusion, and four aneurysms had a Raymond 3 occlusion. Eight aneurysms had better angiographic outcomes versus one aneurysm with a worse angiographic outcome since the re-treatment.

Conclusion

While there is a low rate of treatment failure following use of the PED, re-treatments can be performed in a safe and effective manner and lead to continued angiographic improvements on long term follow-up.

Disclosures

M. Park: None. M. Nanaszko: None. M. Sanborn: None. K. Moon: None. C. McDougall: None. F. Albuquerque: None.
E-005 Short-term Outcomes of Acute Ischemic Stroke Patients with MCA/ICA Occlusion Excluded for Intra-arterial Reperfusion Therapy
Authors: Honarmand A , Beck R , Soltanolkotabi M , Ansari S , Shaibani A , Daruwalla V , Hurley M
Published: July 2014

Introduction

Large-vessel occlusions account for 45% of patients with acute ischemic stroke (AIS) presenting to the emergency departments in the United States. Many of these patients may not be eligible candidates for intravenous tPA therapy; however, they may benefit from receiving intra-arterial therapy (IAT). Optimal patient selection plays a pivotal role in identification of those AIS patients who may benefit from IAT. However, no method has been introduced as the gold standard for patient selection among neurointerventionalists in the clinical practice. Therefore, many of the stroke patients with large vessel occlusion presenting in the acute setting do not receive IAT.

We aimed to review the short-term outcome of AIS patients with large vessel occlusion who were not selected for IAT.

Methods

We retrospectively reviewed consecutive AIS patients with National Institute of Health Stroke Scale (NIHSS) score of more than 8 and CTA/MRA verified MCA/ICA occlusion who did not receive endovascular thrombectomy/thrombolysis treatment. Data were collected on demographics, initial NIHSS score, the cause for not being eligible for endovascular intervention, and mortality rate during the first 30 days. Eligibility for undergoing IA thrombectomy/thrombolysis treatment based on CT/MR perfusion imaging profiles was defined as CBV/DWI infarct core 20% infarct core.

Results

Thirty one AIS patients (19 F/12 M; mean age of 78.1(32–93; SD: ±13.44 years) were studied. Mean and median baseline NIHSS score were 20.06 (8–40; SD: ± 8.25) and 19, respectively. Mortality in the first 30 days was 38.7% (12/31) and 6 patients (20%) were referred to hospice. Among fourteen patients who did not undergo endovascular thrombectomy/thrombolysis reperfusion therapy due to the unfavorable perfusion profile, six patients expired and 4 patients were referred to the hospice, in the first 30 days. Seventeen patients were not intervened due to improvement in NIHSS score following receiving intravenous tPA, advanced age, severely high NIHSS score, and high risk clinical profile for intervention. Among these patients, six patients expired and two patients were referred to hospice.

Conclusion

In this cohort of patients, we observed relatively high mortality rate and poor short-term clinical outcomes in AIS patients with large vessel occlusion who were not selected for IAT. Patients excluded from receiving IAT using imaging-based methods, generally had worse outcomes compared with those patients who were selected based on clinical evaluation. Efforts should be made to develop a standard and accurate patient selection method for identification of the optimum number of AIS patients with large vessel occlusion who may benefit from IAT.

Disclosures

A. Honarmand: None. R. Beck: None. M. Soltanolkotabi: None. S. Ansari: None. A. Shaibani: None. V. Daruwalla: None. M. Hurley: None.
E-011 TICI Quantified: Automated Cerebral Revascularization Grading in Acute Ischemic Stroke
Authors: Sattar A , Asif K , Teleb M , Castonguay A , Issa M , Zaidat O
Published: July 2014

Introduction

Cerebral angiographic revascularization grading is the primary method for measuring the angiographic success of acute ischemic stroke (AIS) endovascular therapy and is one of the strongest predictors for clinical outcome. Of the many reported scales, the modified Treatment in Cerebral Ischemia (mTICI) scale is the preferred grading scale for assessment of revascularization. Currently, mTICI grading is based on visual crude estimations by the operator, which may introduce error and bias in to the evaluation. Here, we present an update on our on-going study to automatize mTICI and provide a more accurate and precise grading tool: Quantified TICI (qTICI).

Methods

Phase one of the project is to develop a database of 15–30 patients with an aplastic/hypoplastic anterior cerebral artery (ACA) in order to establish the standard average and predicted 100% qTICI for the isolated middle cerebral artery (MCA) territory. To map the MCA territory, a retrospective review of patients between the ages of 18–85 was performed from our Digital Subtraction Angiography (DSA) database at the Medical College of Wisconsin. All consecutive cases with aplastic/hypoplastic ACA (to minimise contaminating blood flow from the ACA territory) are included in this study. Existing Siemens software is currently in use to estimate the territory of normal capillary blush and establish normal blood flow values in this database.

Results

We have identified 19 consecutive patients with aplastic/hypoplastic ACA between the ages of 18–85, from our DSA database of over 3000 cases. Nine patients had aplastic A1 and 10 had hypoplastic A1 segments of the ACA. Once normal capillary blush of the MCA territory has been established and automatized, we will use those normalised values per age to compare the capillary blush and blood flow of the pathological cases- a cohort of 20–25 patients who have stroke secondary to MCA occlusion. Values of qTICI will be compared and validated using standard visual estimation of mTICI. Clinical correlation of qTICI with outcome will also be performed. The goal is to establish software that will accurately grade mTICI on a continuous scale rather than using the current crude visual estimation with wide range 4 strata, which will eliminate the operator dependent bias and increase the precision and accuracy of the revascularization grading.

Conclusion

The qTICI Grading Software once developed will have the potential to revolutionise the way clinicians and interventionalists grade revascularization post AIS endovascular therapy. The clinical implications of establishing automatized and quantified revascularization scale is critical in improving treatment safety and efficacy.

Disclosures

A. Sattar: None. K. Asif: None. M. Teleb: None. A. Castonguay: None. M. Issa: None. O. Zaidat: None.