bluuebunny/crossref_metadata_2025 huggingface dataset:
Distinct Contributions of Interleukin-1α (IL-1α) and IL-1β to Innate Immune Recognition of Pseudomonas aeruginosa in the Lung
Authors: Al Moussawi Khatoun , Kazmierczak Barbara I.
Published: July 2014

The bacterial pathogenPseudomonas aeruginosacauses acute infections associated with significant morbidity and mortality.P. aeruginosaelicits strong innate immune responses in immunocompetent hosts, and the resulting recruitment of neutrophils to the site of infection is necessary for bacterial clearance.P. aeruginosalipopolysaccharide and flagellin are recognized by extracellular Toll-like receptors, but the most rapid responses to infection occur when cytosolic receptors sense flagellin or type 3 secretion system (T3SS) structural proteins. The subsequent activation of the NLRC4 inflammasome and caspase-1 generates an interleukin-1β (IL-1β) signal that is required for the rapid neutrophilic response. A T3SS effector, exotoxin U (ExoU), can inhibit activation of the NLRC4 inflammasome and caspase-1. Thus, our observation that IL-1 receptor (IL-1R)-mediated signals were still required to initiate a response to ExoU-producing bacteria was unexpected. As both IL-1α and IL-1β signal via the IL-1R, we examined immune responses in mice lacking either of these cytokines. IL-1β-deficient mice responded to ExoU-producingP. aeruginosabacteria similarly to wild-type animals; however, IL-1α-deficient mice had an attenuated immune response. The situation was reversed following infections by ExoU-negative bacteria: here, IL-1α was dispensable for neutrophil recruitment, while IL-1β was required. IL-1α secretion by macrophages infected with ExoU-producingP. aeruginosaisolates was independent of both caspase-1 and caspase-11. This study documents distinct roles for IL-1α and IL-1β in the response toP. aeruginosainfection as a function of the T3SS effectors produced by the infecting strain. The redundancy of these two cytokines nonetheless allows the infected host to mount a response to ExoU-positive and -negative bacterial isolates.
Acute parvovirus B19 infection in identical twins unmasking previously unidentified hereditary spherocytosis
Authors: Forde Donall G , Cope Alison , Stone Ben
Published: July 2014

Identical Caucasian male twins, previously fit, presented 1 week apart with short histories of fever and lethargy. The twins were febrile at presentation with profound pancytopaenia and evidence of haemolysis. There was no rash or arthralgia. Both required multiple red cell transfusions. The twins had positive IgM serology for Epstein-Barr virus (EBV), cytomegalovirus (CMV) and parvovirus B19. EBV viral capsid antigen and Epstein-Barr nuclear antigen IgGs were also positive however, suggesting past EBV exposure. Parvovirus B19 DNA was detected from peripheral blood PCR; CMV and EBV DNA PCRs were negative. Convalescent serology demonstrated no evolution of the CMV serological response, that is no IgG to CMV developed which implies an initial non-specific polyclonal IgM response. The twins recovered fully over 7 days, the first with a course of prednisolone and the second spontaneously. They were diagnosed with hereditary spherocytosis on convalescent blood films. On further questioning, a family history of hereditary spherocytosis was eventually revealed. The twins’ maternal grandmother was known to have the condition asymptomatically. Their mother had prior to this never been tested, but later bloods would reveal a compatible biochemical picture.
Intravitreal ranibizumab for bilateral choroidal neovascularisation in a patient with angioid streaks
Authors: Yilmaz Ihsan , Ozkaya Abdullah , Alkin Zeynep , Yazici Ahmet Taylan
Published: July 2014

Angioid streaks are described as irregular lines deep into the retina, configured in a radiating fashion which results from breaks in Bruch’s membrane. Optic nerve head drusen are acellular, globular deposits located within the optic nerve head. Angioid streaks and optic nerve head drusen may coexist in patients with pseudoxanthoma elasticum. Both disorders may cause choroidal neovascularisation. In this case report we aimed to present a 48-year-old man with pseudoxanthoma elasticum. The patient had bilateral choroidal neovascularisation secondary to angioid streaks and was treated with intravitreal ranibizumab injections. Visual acuity was increased and maintained at the same level during the follow-up time. There was no complication related to the injection.
Endovascular therapy of extracranial carotid artery pseudoaneurysms: case series and literature review
Authors: Seward Christopher J , Dumont Travis M , Levy Elad I
Published: July 2014

Background

Experience with endovascular therapy of extracranial carotid artery pseudoaneurysm (ECAP) has been growing, and various results suggest it as a suitable treatment option. We present a consecutive case series of patients with ECAPs treated with endovascular therapy, and a pertinent literature review.

Methods

A prospectively maintained database of neuroendovascular procedures was retrospectively reviewed for cases of ECAP treated between January 2007 and December 2012. The primary outcome of interest was incidence of periprocedural (within 30 days) neurologic and cardiopulmonary complications. PubMed was searched for relevant endovascular studies from 2000 to 2012 for the review.

Results

In our series, 12 patients with 14 ECAPs received stents, with or without coils. No perioperative neurologic or cardiopulmonary complications occurred. Median duration of clinical follow-up was 6.25 months (range 0–50 months), and median duration of imaging follow-up was 6.25 months (range 0–50 months), with eight patients asymptomatic and three showing improved symptoms (one patient with two lesions was lost to follow-up). Literature review revealed an overall primary outcome of 8.6% and no procedure related deaths.

Conclusions

Endovascular treatment of ECAP is safe and effective at improving symptoms. There were no perioperative or permanent neurologic sequelae in the 11 patients with follow-up, and all symptomatology related to ECAP improved or resolved with treatment.
Onyx embolization of an avulsed thalamoperforator following endoscopic colloid cyst and lamina terminalis fenestration
Authors: Turner Raymond D , Chaudry Imran , Turk Aquilla , Spiotta Alejandro
Published: July 2014

A patient presented with headaches and was found to have a colloid cyst in the third ventricle and ventriculomegaly. The patient underwent endoscopic colloid cyst resection and third ventriculostomy without incidence. Prior to emergence, a blown right pupil was acutely noted, and bright red blood emanated from the ventricular drain that was routinely placed in the endoscopy tract at the conclusion of the procedure. CTangiography demonstrated active extravasation from the pre-pontine cistern into the third ventricle and subarachnoid space. Emergency DSA confirmed active extravasation from an avulsed thalamoperforator arising from the proximal right P1 posterior cerebral artery, which was immediately embolized without incident.
O-010 Radiation Safety in Neurointervention: Is it Time for Dose Reference Levels?
Authors: Slater L , Hadley C , Soufan C , Yu H , Holt M , Chong W , Maroulis H , Stuckey S , Chandra R
Published: July 2014

Background

Therapeutic neurointerventional (NI) procedures have become a significant source of radiation exposure during the treatment of cerebrovascular disease. While there are well-established radiation dose reference levels (DRLs) for diagnostic imaging, no similar NI DRLs are available. We analyzed the patient radiation dose for therapeutic NI procedures at a tertiary teaching hospital, with an aim to develop local DRLs that could form the foundation for developing national NI radiation safety guidelines.

Method

Retrospective analysis of radiation dose area product (DAP) in Gy. Cm2for consecutive patients undergoing therapeutic NI procedures between July 2011 and April 2014 was performed. NI procedures were categorized into arteriovenous malformation (AVM) embolization, cerebral aneurysm embolization (primarily coiling vs balloon/stent assisted) and cerebral vasospasm procedures. Median and inter-quartile radiation dose levels were calculated for each NI category. The 75thpercentile was deemed to be the local DRL. Wilcoxon signed-rank test was performed for statistical correlation.

Results

A total of 303 NI procedures were included. Patients undergoing AVM embolization received a significantly higher radiation dose (n = 44; median 338 Gy. Cm2[IQR 225–528 Gy. Cm2]) than patients undergoing cerebral aneurysm embolization (n = 188; median 211 Gy. Cm2[IQR 130–328 Gy. Cm2]; p = 0.003). Patients treated with primary coiling received a significantly lower radiation dose (n = 96; median 170 Gy. Cm2[IQR 125–282 Gy. Cm2]) than patients undergoing stent/balloon assisted aneurysm embolization (n = 92; median 241 Gy. Cm2[IQR 145–369 Gy. Cm2]); p = 0.0002). Patients undergoing cerebral vasospasm procedures (n = 71) received median 161 Gy. Cm2[IQR 106–219 Gy. Cm2] of radiation.

Conclusion

Therapeutic NI procedures are a significant source of radiation exposure, particularly for AVM embolization. Proposed NI radiation DRLs based on the 75thpercentile for DAP were 528 Gy. Cm2, 328 Gy. Cm2and 219 Gy. Cm2for AVM embolization, cerebral aneurysm embolization and cerebral vasospasm procedures respectively.

Disclosures

L. Slater: None. C. Hadley: None. C. Soufan: None. H. Yu: None. M. Holt: None. W. Chong: None. H. Maroulis: None. S. Stuckey: None. R. Chandra: None.
E-034 Acute Shortening of Carotid Wallstent after Successful Carotid Artery Stenting
Authors: Nagayama T
Published: July 2014

Carotid artery stenting (CAS) for carotid artery stenosis has become an alternative for treating patients not eligible for carotid endarterectomy (CEA). Even though the CAS is relatively simply in many cases, various complications such as distal embolization and hyperperfusion can occur. We repot a rare case of CAS using the Carotid Wallstent, which was complicated by acute shortening of the stent after successful CAS, and discuss the possible mechanisms of this complication.

A 79-year-old male presented with amaurosis fugax in the left internal carotid artery (ICA) territory. Digital subtraction angiography (DSA) showed severe left ICA stenosis (NASCET criteria; 90%). CAS was performed under local anesthesia using a 10 × 24 mm Carotid Wallstent and PercuSurge GuardWire protection system. Immediate post-stent angiography showed successful stent implantation without any complication. A follow-up cervical x-ray film a half day after stenting showed stent shortening toward the proximal end, and DSA obtained 4 days later revealed residual stenosis of the distal portion of the stent. Therefore an additional CAS was done using a Precise stent.

Shortening of Carotid Wallstent seemed to be induced by marked diameter mismatch between the distal and proximal ICA or the ICA and CCA, and can occur even after successful CAS. An expansion of Carotid Wallstent at the large diameter of ICA and CCA level might have caused stent shortening, which pulled the distal end of the stent downward. Therefore, short term follow-up evaluation is important to detect unexpected complications such as stent shortening.

Disclosures

T. Nagayama: None.
E-053 Multi-Modality Management of Posterior Fossa Arteriovenous Malformations: Clinical and Angiographic Outcomes
Authors: Robert T , Blanc R , Ciccio G , Gilboa B , Boissonnet H , Fahed R , Redjem H , Pistocchi S , Bartolini B , Piotin M
Published: July 2014

Background

Infratentorial arteriovenous malformations (AVM) are rare entities, representing only 7–15% of cerebral AVMs. The concentration of eloquent neurological systems and the high rate of bleeding presentation of AVMs in this location complicate the management of such lesions. New therapeutic options, especially in endovascular neurosurgery, have fundamentally modified the strategy and also the outcome of posterior fossa AVMs.

Methods

Between 1999 and 2013, baseline, clinical and angiographic data of cerebral AVMs were prospectively collected. We analyzed data from patients treated for a posterior fossa AVM, focusing on risk factors for bleeding, and clinical and angiographic outcomes.

Results

Sixty-nine patients (mean age 34 years, male to female ratio: 2) were consecutively treated for an infratentorial AVM. Fifty-seven presented with haemorrhage, 6 with focal neurologic deficits, the 6 cases were diagnosed incidentally. The Spetzler-Martin grade was <3 in 39 (56.5%) cases. Associated aneurysms were noted in 43.5% of cases. All patients had been treated by endovascular procedures, associated with microsurgical resection in 9 patients and with stereotactic radiosurgery in 6 cases. Mean follow-up was 28.5 months, with angiographic exclusion of the AVM in 72.5% of cases; 21.7% of patients presented a modified Rankin Score ≥3 at follow-up.

Conclusions

Endovascular embolization is a valid and secure approach for posterior fossa AVMs although a large number of sessions is necessary to achieve complete obliteration. Multi-disciplinary discussion and management is crucial to obtain the best cure rate without increasing procedural risks.

Disclosures

T. Robert: None. R. Blanc: None. G. Ciccio: None. B. Gilboa: None. H. Boissonnet: None. R. Fahed: None. H. Redjem: None. S. Pistocchi: None. B. Bartolini: None. M. Piotin: None.
E-054 Angiographic Factors Influencing the Success of Endovascular Treatment of Arteriovenous Malformations involving the Corpus Callosum
Authors: Robert T , Blanc R , Gilboa B , Ciccio G , Fahed R , Redjem H , Pistocchi S , Bartolini B , Piotin M
Published: July 2014

Object

Arteriovenous malformations (AVM) of the corpus callosum were rare lesions, accounting for 9–11% of brain AVMs. Microsurgical resection of such lesions remained difficult regarding deep location and possible neuropsychological disasters of extended callosal resection. The introduction of endovascular and radiation therapies fundamentally changed the outcome of these lesions.

Methods

Since 1995, clinical and angiographic data of cerebral AVMs were prospectively collected. We reviewed data from patients treated for an AVM of the corpus callosum and discussed factors influencing the endovascular approach of such lesions.

Results

Thirty-eight patients (mean age: 31 year) were consecutively treated by endovascular techniques. 78.9% (30 cases) presented with intracranial haemorrhage. 15 AVMs (39.5%) were anterior, 18 (47.4%) posterior and 5 (13.1%) holocallosal. The Spetzler-Martin grade was I in 2 cases (5.2%), II in 20 (52.6%), III in 9 (23.7%), IV in 6 (15.8%) and V in 1 case (2.6%). The nidus was compact in 19 cases (50%), diffuse in 13 (34.2%) and multifocal in 6 (15.8%). Both anterior and posterior circulation branches fed 14 nidi (36.8%). The venous drainage was superficial in 3 cases (7.9%), deep in 28 (73.7%) and both in 7 (18.4%). 104 sessions have been performed with a procedural complication rate of 6.7%. The mean follow-up was 43.6 months with a last mRS <3 in 33 cases (86.8%). 22 patients (57.9%) have been totally cured. Univariate analysis of factors influencing the success of endovascular treatment showed that Spetzler-Martin grade ≥3 (p = 0.046), nidus >30 mm (p = 0.02), extension in eloquent area (p = 0.03) and holocallosal type (p0.005) significantly diminish chances to cure the AVM.

Conclusions

AVMs of the corpus callosum seems to be difficult to treat with endovascular therapy alone. The goal of embolization should be the prevention of (re) bleeding and the decrease of nidus size. When endovascular treatment could not achieve to the complete cure of the AVM, associated radiotherapy permitted to increase the occlusion rate.

Disclosures

T. Robert: None. R. Blanc: None. B. Gilboa: None. G. Ciccio: None. R. Fahed: None. H. Redjem: None. S. Pistocchi: None. B. Bartolini: None. M. Piotin: None.
E-063 Physicians Use Perfusion Imaging to Aid in Diagnosis and Treatment Decisions for Acute Ischemic Stroke
Authors: Seifert K , Wiener J , DeOrchis D
Published: July 2014

Background

Recently, perfusion imaging has been utilised to provide visualization of at risk ischemic tissue that would benefit from revascularization treatment; however, current research differs in recommendations on the use of perfusion. The purpose of our study was to evaluate whether perfusion imaging helped guide diagnosis and treatment of ischemic strokes.

Methods and materials

We conducted a retrospective review for patients who received perfusion imaging and/or treatment for ischemic stroke over a three-year period. We reviewed the progression of diagnosis, treatment or lack of, complications of treatment, and whether the imaging played a role in the treatment plan.

Results

The majority of patients in this study had treatment that was influenced by perfusion imaging. This was most evident in our population of patients that received intra-arterial therapy as 95% of these patients received treatment based on the results of imaging. There was an impact in the decision to not treat patients who had completed strokes on perfusion imaging, preventing unnecessary treatment and complications. In addition, our perfusion imaged patients were found to have a significantly longer time to treat than those that did not receive imaging, extending beyond the three-hour treatment window with an average of 4.88 h without an increased risk of complications or decrease in clinical outcome.

Conclusion

Perfusion imaging can be used in the real world setting as a tool to guide patient diagnosis and treatment, to select patients with salvageable tissue to receive intra-arterial treatment outside the standard intravenous time window.

Disclosures

K. Seifert: None. J. Wiener: None. D. DeOrchis: None.
E-064 Safety and Efficacy of Balloon-Assisted Coiling of Intracranial Aneurysms: A Single-Center Study
Authors: Ramakrishnan V , Quadri S , Sodhi A , Cortez V , Taqi M
Published: July 2014

Objective

Balloon-assisted coil embolization has become an important adjunct in the endovascular treatment of intracranial aneurysms, particularly those with challenging anatomy. The need for anti-platelet agents when deploying intracranial stents, which could lead to increased morbidity and mortality in patients with ruptured aneurysm, has made the use of balloon-assisted coil embolization (BACE) a more prevalent approach in the last several years for subarachnoid haemorrhage. We evaluated the safety and efficacy of balloon remodeling at our institute.

Methods

We performed a retrospective review of all patients who underwent endovascular coiling of aneurysms from June 2012 to February 2014.

Results

A total of 81 procedures were performed on 73 patients and 74 aneurysms were treated at our institution with endovascular techniques. 45 of 74 (60.81%) were ruptured aneurysms and venticulostomy was required in 31 (68.8%) of these patients. Balloon remodeling was used in 44 of 74(59.4%) of cases. More than 1 aneurysm were treated in the same procedure in 7 cases. 4 aneurysms were treated in 2 stages while 1 aneurysm required 3 stages for treatment. The following adverse events occurred: Thrombus formation 5/44 (11.3%); Vessel perforation from balloon 0/44 (0%); Perforation by coil occurred in 5/44 (11.3%) of cases. Dissection 0/44 (0%) and stroke related to thrombus formation 0/44 (0%). 4 out of 5 thrombi were formed in ruptured aneurysms. Balloon inflation time ranged from 1–5 min. Balloon inflation time did not correlate to thrombus formation. Neck diameters treated with balloons measured from 1.5 mm to 7.83 mm.

Conclusions

In our single-center study, balloon-assisted coiling was not associated with serious complications. Minimal intra-operative thrombi which were formed resolved with almost no adverse events in patient. Further studies will need to be performed on long term outcomes of these patients, however, balloon-assisted coiling has emerged as an important adjunct in the endovascular treatment of aneurysms.

Disclosures

V. Ramakrishnan: None. S. Quadri: None. A. Sodhi: None. V. Cortez: None. M. Taqi: None.
E-065 Clinical Treatment Result of Carotid Artery Stenting in Japan: Comparison of Periprocedural Ischemic Complication by Embolic Protection Devices
Authors: Takayama K , Myouchin K , Wada T , Nakagawa H , Kichikawa K , Kurokawa S
Published: July 2014

Carotid artery stenting (CAS) was approved in Japan in October 2007. Since then, several embolic protection devices (EPD) and stents for CAS have become available.

We investigated the clinical treatment results and periprocedural ischemic complications of CAS by using a standard procedure.

We retrospectively analyzed 312 patients with 329 carotid artery stenoses (272 men; age 39–97 years [mean 73.7 years]; symptomatic stenosis, 144 lesions; mean stenosis rate, 82.1%) who underwent CAS from October 2007 to March 2014. The technical success rate, periprocedural ipsilateral ischemic stroke, and incidence of ischemic lesions within 48 h after CAS with EPD were assessed using diffusion weighted images (DWIs).

All cases of CAS were successful. Among nine patients (2.7%) who suffered a stroke, a major stroke occurred in one patient (0.3%) and minor strokes in eight patients (2.4%). The EPDs and stents used were as follows: Angioguard XP/RX(AG), 141; Filterwire EZ (FW), 128; MoMa Ultra (MU), 52; Spider FX, 2; Percusurge, 2; Precise (PS), 215; Carotid Wallstent (CWS), 97; Protégé (PT),14; PS and CWS, 2; PS and PT, 1. Over 50 cases of stroke and new ischemic lesions by EPD were observed in AG, 2.8% (4/141) and 33.1% (46/139); FW, 2.3% (3/128) and 22.0% (28/127); and MU, 3.8% (2/52) and 41.1% (21/51), respectively.

The CAS by the standard procedure showed very good clinical treatment results. The incidence of ischemic lesions on DWI was much lower in FW than in the other EPDs.

Disclosures

K. Takayama: None. K. Myouchin: None. T. Wada: None. H. Nakagawa: None. K. Kichikawa: None. S. Kurokawa: None.
E-067 Balloon assisted Pre-operative Embolization of Hypervascular Metastatic Lesions to the Spine
Authors: Jagadeesan B , Mortazavi S , Moen S , Grande A , Tummala R
Published: July 2014

Introduction

It is common to perform pre-operative embolization of metastatic lesions to the spine from hyper-vascular tumors. Typically, a microcatheter is navigated into a prominent arterial feeder to the tumor arising from a segmental artery or bronchial artery. Thereafter, particles or liquid embolic agents are injected into the tumor through the microcatheter, while taking care to avoid reflux into the proximal segmental artery or the aorta. However, occasionally, there may be a diffuse network of small arterial feeders arising from the segmental artery, which supply the tumor. None of these small arteries maybe amenable to selective catheterization, and embolization may be challenging due to the risk of reflux of embolic agent into the parent artery or aorta. Herein, we report our experience with embolising such metastatic lesions by injecting particles through a dual lumen balloon microcatheter positioned within the main segmental artery and using the inflated balloon to prevent reflux into the aorta.

Materials and methods

We performed pre-operative embolization for hyper vascular vertebral metastases (two thoracic spine and 2 lumbar vertebrae) in a series of 3 patients (2 male and 1 female, mean age 53) with metastatic renal cell carcinoma at our institution using the 4 × 10 mm Sceptre C balloon microcatheter. In all patients, after ensuring that there was no radiculomedullary artery arising from the segmental artery supplying the tumor feeders, a 4 × 10 mm Sceptre C balloon microcatheter was navigated into the proximal aspect of the artery. The balloon was then inflated such that there was a tight seal across the origin of the artery from the aorta and embolization of the tumor was carried out with 150–300 microns PVA particles. Intermittently, the balloon was slowly deflated and DSA was carried out to assess changes in the tumor “blush”. Embolization was carried out until there was elimination of the tumor blush.

Results

The Sceptre C balloon microcatheter could be successfully navigated into the parent segmental vessel and inflated proximally across the origin of the vessel in all patients. Subsequent particle embolization resulted in complete elimination of the tumor “blush” in the vertebral body in every instance. There were no adverse events such as segmental arterial dissection, balloon rupture or reflux of particles into the aorta in any patient.

Conclusion

Pre-operative embolization of hypervascular spinal mestastatic lesions can be safely carried out using a balloon-assisted technique with a dual lumen balloon microcatheter when traditional selective catheterization of feeder vessels is not feasible.

Disclosures

B. Jagadeesan: None. S. Mortazavi: None. S. Moen: None. A. Grande: 2; C; Covidien, Integra. R. Tummala: 2; C; Lake Regional.
E-069 Validation of a New Modified Capillary Index Score Angiographic Real Time Assessment of Dead vs Salvable Tissue
Authors: Teleb M , Noufal M , Sattar A , Wazni W , Issa M , Asif K , Gheith A , Castonguay A , Zaidat O
Published: July 2014

Background

The original capillary index score publication only included patients that had full digital subtraction angiograms (DSA) before stroke intervention. This CIS was a single center publication with no external validation. Many centers do not perform a full DSA to assess all collaterals before intervention.

Hypothesis

A modified capillary index score (mCIS) using only the ICA injection can predict outcome in MCA occlusions (only MCA occlusions included).

Objective

Validate the utility and use of a modified capillary index score (mCIS) to assess outcomes and improvement in acute stroke patients.

Methods

mCIS was assessed on all consecutive patients with an MCA occlusion with complete database information. NIHSS, recanalization (mTICI), and mRS before and after treatment were assessed. mCIS of 2–3 was considered favorable as per original publication. Correlation between favorable CIS, NIHSS improvement, and mRS (0–3 good) were assessed.

Results

33 patients with MCA occlusion with complete data sets where assessed. 63.6% (21/33) had a favorable mCIS (2–3) and 36.4% had a poor mCIS(0–1). Recanalization of TICI 2b or greater was achieved in 42.9% (9/21) of patients with favorable mCIS and 58.3% (7/12) of patients with poor mCIS. Of those with favorable mCIS 28.6% (6/21) had a good mRS of ≤3 at discharge vs those with poor mCIS while those with a poor mCIS 33.3% had a good mRS at discharge. However, mortality was lower in favorable mCIS vs. poor mCIS (9.5 vs. 33.35, p = 0.09).

Conclusions

A modified CIS is did not predict the functional outcome but may be predictor of mortality. Small sample size, lack of long-term follow up, or the lower rate of recanalization of those with favorable mCIS could have contributed to the negative outcome. A prospective or larger study with long term follow up is needed for validation.

References

Al-Ali F, Jefferson A, Barrow T,et al. The capillary index score: rethinking the acute ischemic stroke treatment algorithm. Results from the Borgess Medical Center Acute Ischemic Stroke Registry. J Neurointerv Surg.2013;5(2):139–143. doi:10.1136/neurintsurg-2011-010146

Capillary Index Score, Baseline Characteristics and Outcomes

Favorable mCIS Unfavorable mCIS P Value

Baseline NIHSS 14 + /-6.9 18.3 + /-3.9 0.051

Age 64.3 + /-16.6 68.8 + /-4.9 0.453

Good Recanalization (2b-3) 42.9% (9/21) 58.3% (7/12) 0.391

NIHSS at Discharge 10.8 + /-7.5 15 + /-2.5 0.099

NIHSS at Discharge in TICI 2b and higher 5.8 + /-4.2 13.4 + /-13.7 0.067

Mortality 2/21 (9.5%) 4/12 (33.33%) 0.093

Good Outcome (mRS < = 3) 28.6% (6/21) 33.33% (4/12) 0.775

Good Outcome in TICI2b or higher

12 mRS < = 3) 5/9 (55.6%) 4/7 (57.1%) 0.0949

Disclosures

M. Teleb: None. M. Noufal: None. A. Sattar: None. W. Wazni: None. M. Issa: None. K. Asif: None. A. Gheith: None. A. Castonguay: None. O. Zaidat: 2; C; Penumbra, Stryker, Covidie. 3; C; Penumbra, Stryker, Covidien.
E-070 Acute Recanalization with Stenting for Wake-up Stroke
Authors: Sung S , Lee T
Published: July 2014

Background

Approximately 16% to 28% of acute ischemic stroke patients have symptoms on awakening. Because of unclear time of symptom onset, these patients are ineligible for standard intravenous thrombolysis. Some of these patients may be benefit from emergent endovascular recanalization with stenting. The purpose of this study was to evaluate the feasibility and safety of emergent endovascular recanalization for wake-up stroke (WUS).

Methods

We reviewed 10 patients with WUS and an occlusion in carotid and middle cerebral artery who were treated with stenting. We analyzed clinical and angiographic outcomes. Recanalization was evaluated by the Thrombolysis in Cerebral Infarction score. Clinical outcome was assessed at 90 days by the modified Rankin Scale.

Results

The median NIHSS score on admission was 19 points (range 8–24). The median time from stroke symptom recognition to arrival at emergency department was 144 min (range 57–230 min). The median time from stroke symptom recognition to recanalization was 312 min (range 227–344 min). The median time from last seen normal to recanalization was 11 h 23 min (range 495–830 min). Occlusion sites were supraclinoid ICA in 2 (all: left), proximal ICA in 3 (left: 2, right: 1) and M1 of MCA in 5 patients (left: 2, right: 3). Successful recanalization was achieved in all patients. A small subarachnoid haemorrhage occurred in 1 patient during intervention. No symptomatic ICH occurred in any patients. Neurologic improvements in the NIHSS score (median 9, range 4–17) at 7 days after stenting achieved in 7 patients. At 90 days, an mRS of ≤2 was achieved in 2 patients (20%). One patient died within hospital stay due to sepsis.

Conclusion

Emergent stenting can be feasible and possibly safe for achieving successful recanalization and improving on the NIHSS in patients with WUS. However, clinical outcome was still not satisfactory.

Disclosures

S. Sung: None. T. Lee: None.
O-016 Development and Validation of an Endovascular Chemotherapy Filter Device for Removing High-Dose Doxorubicin from the Blood:In VivoPorcine Study
Authors: Patel A , Chin A , Yang J , Thorne B , Saeed M , Wilson M , Hetts S
Published: July 2014

Purpose

A novel disposable endovascular chemotherapy filter (CF) device was developed to remove excess doxorubicin (Dox) from the blood during intra-arterial chemotherapy delivery to prevent systemic toxicities. Previous proof-of-concept established the capacity of the filter to bind Dox in swine serum in vitro. In this study, CF navigation, deployment and in vivo Dox binding was evaluated in the porcine inferior vena cava (IVC).

Materials and methods

An 18 Fr CF device was constructed with an ion-exchange membrane attached to an expandable 28 mm diameter Nitinol frame. Under X-ray fluoroscopy and contrast venography, the CF was percutaneously introduced via the internal jugular vein and deployed in the porcine infrarenal IVC. 50 mg of Dox (2 mg/ml) was injected over 10 min in the IVC below the CF device. Venous catheters with tips proximal and distal to the CF device in the infrarenal IVC obtained pressures and blood samples for Dox concentrations over 90 min across the CF device membrane.

Results

The CF device was successfully introduced and deployed in the infrarenal IVC in vivo. Visualization under X-ray fluoroscopy verified the proper placement and mechanical expansion of the Nitinol framework. In a 90 min study, the device was biocompatible, not leading to hemodynamic disturbances: pressure measurements taken throughout the experiment yielded a max gradient of 17 mmHg across the CF membrane. Venography demonstrated non-flow-limiting thrombus associated with the CF device after 90 min of deployment (swine were not heparinized). Significant Dox binding was noted with an 85%, 74%, and 83% decrease in relative pre- versus post-filter Dox concentrations at times 3, 10, and 30 min, respectively after Dox injection.

Conclusion:

We developed a biocompatible CF device that can be safely introduced, deployed, and removed from the IVC in vivo. The CF device demonstrated significant Dox binding, and could serve as a platform technology in drug therapy to allow for higher regional doses of drug while limiting systemic toxicity. In future in vivo experiments, animals or the CF device itself may be heparinized in order to prevent thrombosis. When fully developed, indications for this device could include head and neck cancer, with the device deployed in the superior vena cava or internal jugular veins during selective IA chemotherapy.

Disclosures

A. Patel: 1; C; NIH-NCI. 4; C; ChemoFilter. A. Chin: 1; C; NIH-NCI. 4; C; ChemoFilter. J. Yang: None. B. Thorne: None. M. Saeed: None. M. Wilson: 1; C; NIH-NIBIB, NIH-NCI. 4; C; ChemoFilter. S. Hetts: 1; C; NIH-NIBIB, NIH-NCI, Siemens, Covidien. 2; C; Stryker, Penumbra, Silk Road Medical, Medina Medical. 4; C; ChemoFilter, Medina Medical, DriftCoast.
O-017 Minimally Invasive Angiographic CT Guided Evacuation of Parenchymal and Ventricular Haemorrhage Using the Apollo System: Proof of Concept in a Cadaver Model
Authors: Fiorella D , Arthur A
Published: July 2014

Introduction

Apollo (Penumbra Inc, Alameda, CA) is a low profile irrigation-aspiration system designed for the evacuation of intracranial haemorrhage. We demonstrate the feasibility of using Apollo through a minimally invasive approach using angiographic CT guidance.

Methods

Parenchymal (n = 1) and mixed parenchymal-intraventricular hematomas (n = 1) were created in cadaver heads using a transvascular (n = 1) or transcranial (n = 1) approach. Hematomas were then imaged with angiographic CT ((ACT), dynaCT, Seimens Medical Imaging, Erlanger, GE) and the long axis of the hematoma defined. The ACT data were then used (iGuide, Siemens Medical Imaging) to guide transcranial access to the hematoma-defining the location of the burr hole and the path to the leading edge of the hematoma. A 8F vascular sheath was then placed under live fluoroscopic guidance into the hematoma. A second ACT was performed to confirm localization of the sheath. The hematoma was then demarcated on ACT and the Apollo system was introduced through the 8F sheath under live fluoroscopic guidance (iPilot, Siemens Medical Imaging). Following irrigation-aspiration with Apollo, repeat ACT was performed to document reduction in hematoma volume.

Results

Both transvascular and transcranial techniques were successful in creating intracranial hematomas. Hematomas could be defined with conspicuity sufficient for localization and volumetric measurement using ACT. Live fluoroscopic guidance was effective in navigating a sheath into the leading aspect of a parenchymal hematoma and guiding irrigation-aspiration with the Apollo system. Irrigation-aspiration with Apollo reduced the intracranial haemorrhage volume more than 80% in both cases. The Apollo system was activated for 189 seconds and 300 in the first and second subjects, respectively.

Conclusions

The described cadaver model is a useful means by which to study interventional techniques for intracranial haemorrhage. It seems feasible to use ACT to guide the evacuation of parenchymal and intra-ventricular haemorrhages using the Apollo system through a minimally invasive trans-cranial access.

Disclosures

D. Fiorella: 1; C; Siemens, Penumbra. A. Arthur: 1; C; Siemens, Penumbra.
O-018 Magnetically Assisted Remote-controlled Endovascular Catheter for Interventional MRI:In VitroNavigation at 1.5 T versus X-ray Fluoroscopy
Authors: Hetts S , Losey A , Lillaney P , Cooke D , Thorne B , Saeed M , Arenson R , Wilson M
Published: July 2014

Purpose

To advance the field of endovascular interventional MRI, which could allow real-time assessment of brain tissue viability during acute ischemic stroke interventions, we have developed a prototype MRI compatible magnetically assisted remote controlled catheter (MARC). We sought to compare navigation of a MARC catheter under real-time MRI with manual navigation under MRI and standard x-ray guidance in endovascular catheterization proceduresin vitro.

Materials and Methods

A custom clinical-grade micro catheter prototype with a solenoid coil at the distal tip was deflected with a foot pedal actuator used to deliver current of 300 mA. Investigators navigated the catheter into branch vessels in a cryogel abdominal aortic phantom. This was repeated under MR imaging guidance without magnetic assistance and under conventional x-ray fluoroscopy. MR experiments were performed at 1.5T using a balanced steady-state free precession sequence. The mean procedure times and percentage catheterization success data were determined and analyzed with a linear mixed-effects regression analysis.

Results

The catheter was clearly visible under real-time MRI. One hundred ninety-two (80%) of 240 turns were successfully completed with magnetically assisted guidance versus 144 (60%) of 240 turns with non-assisted guidance (P = 0.001) and 119 (74%) of 160 turns with standard X-ray guidance (P = 0.028). Mean procedure time was shorter with magnetically assisted than with non-assisted guidance under MRI (37 seconds vs 55 seconds, P = 0.001), and time was similar between magnetically assisted and standard x-ray guidance (37 seconds vs 44 seconds, P = 0.045). When stratified by angle of branch vessel, magnetic assistance was faster than nonassisted MRI guidance at turns of 45°, 60°, and 75°.

Conclusion

In this study, a MARC catheter for endovascular navigation under real-time MRI guidance was developed and tested. For catheterization of branch vessels arising at large angles, magnetically assisted catheterization was faster than manual catheterization under MR imaging guidance and was comparable to standard x-ray guidance. This represents a significant advance in MRI guided catheterization and brings the performance of MRI guided stroke interventions closer to clinical reality.

Disclosures

S. Hetts: 1; C; NIH-NIBIB, NIH-NCI, Siemens, Covidien. 2; C; Stryker, Penumbra, Silk Road Medical, Medina Medical. 4; C; Medina Medical, ChemoFilter. A. Losey: None. P. Lillaney: None. D. Cooke: 1; C; Siemens. 4; C; Viket. B. Thorne: None. M. Saeed: None. R. Arenson: None. M. Wilson: None.
O-002 Single Center Experience Comparing Outcomes of Strokes Treated with Mechanical Thrombectomy vs Without Mechanical Thrombectomy Using CTP for Patient Selection
Authors: Vidal G , Milburn J , Pansara A , Jennings B , Sabharwal V
Published: July 2014

Purpose

Most patients with large vessel occlusion (LVO) present with high NIHSS, and it has been shown that initial NIHSS is a predictor of outcomes in patient with acute ischemic stroke. The usefulness of neuroendovascular reperfusion has been a controversial topic. The aim of this study was to compare the outcomes of patients with large vessel occlusion strokes treated with neuroendovascular procedures versus those who received conservative treatment, based on a 2-year (2012–2013), single center experience at Ochsner Medical Center in New Orleans, LA.

Materials and methods

116 consecutive patients who had both CTA confirmed intracranial LVO and CT-Perfusion data upon arrival to our institution were retrospectively studied. Patients with haemorrhages, tandem lesions, or high grade carotid stenosis were excluded from this analysis. The decision to perform endovascular treatment was made by the vascular neurologist and the neuro-interventionalist based on stroke severity and CTA/Perfusion data. Patients in group 1 (n = 50) underwent endovascular revascularization procedures, while patients in group 2 (n = 66) were treated conservatively (medical management alone or with IV t-PA if within treatment window). Presentation NIHSS, risk factors, mortality, discharge NIHSS, discharge mRS, and follow up mRS were recorded and compared. Onset of symptoms to CT-Perfusion time was also studied.

Results

There were no statistical differences in the patient population regarding in age, gender, and risk factors. Also, there was no statistical difference in their presentation/initial NIHSS (17.7 vs. 19.6, p = 0.1236). However, the 2 groups were statistically different in their discharge NIHSS (7.82 vs 18.26, p < 0.00001), discharge mRS (2.42 vs 4.30, p < 0.00001), clinic follow up mRS (2.1 vs 4.12, p < 0.00001), mortality (8% vs 21%, pr = 0.043), and good outcome at discharge (mRS 0–2) (62% vs 14%, pr < 0.00001). There was a statistically significant difference between the groups regarding onset of symptoms to CTA/Perfusion imaging (6h 28 m vs 8 h 26 min, p = 0.0247).

Conclusion

Patients who presented with high NIHSS, LVO, and favorable CT-Perfusion data who underwent neuroendovascular reperfusion treatment had significantly better outcomes and decreased mortality in our patient population, despite having similar stroke severity at presentation. This highlights the importance reperfusion, time to treatment, and collateral flow to maintain tissue viability. This study also suggests that CT-Perfusion imaging may be useful to select patients who will benefit from neuroendovascular reperfusion therapy for LVO ischemic stroke.

Disclosures

G. Vidal: 3; C; Penumbra Inc, Covidien. J. Milburn: 3; C; Penumbra Inc. A. Pansara: None. B. Jennings: None. V. Sabharwal: None.
O-022 A New Protocol for Anticoagulation with Tirofiban during Stenting of Intracranial Aneurysms
Authors: Chalouhi N , Zanaty M , Starke R , Jabbour P , Hasan D
Published: July 2014

Introduction

Stenting techniques such as stent-assisted coiling and flow diversion are increasingly used for treatment of intracranial aneurysms. In previous reports, patients were pretreated were aspirin and clopidogrel prior to the intervention for prevention of thromboembolic complications. Prior studies also often rely on aspirin response and P2Y assessment, which often delays treatment in non-responders. The present study assesses the safety and efficacy of a new protocol for anticoagulation using tirofiban during stent-assisted coiling and flow diversion of intracranial aneurysms.

Methods

In this prospective study, all patients received a 0.10 mcg/kg/min maintenance infusion of tirofiban intraoperatively without a loading dose. The infusion was started immediately after deployment of the stent or flow diverter and continued for 12 h following the procedure. No patient was pretreated with aspirin or clopidogrel. Data on procedural safety was prospectively collected.

Results

A total of 128 aneurysms were treated with this protocol. Mean patient age was 56.2 years. Of these patients, 82 underwent stent-assisted coiling and 46 underwent flow diversion with the Pipeline Embolization Device (PED). Twenty-eight patients (22%) were treated in the setting in subarachnoid haemorrhage. There were only 2 (1.6%) thromboembolic complications and 2 (1.6%) haemorrhagic complications (1 subclinical worsening of the computed tomographic appearance of a subarachnoid haemorrhage and 1 post-PED parietal haemorrhage that was managed conservatively) in the series. The rate of treatment-related permanent morbidity and mortality were only 0.8% and 0%, respectively.

Conclusion

The results of this study suggest that a protocol of anticoagulation with a maintenance infusion of tirofiban during stent-assisted coiling and flow diversion of intracranial aneurysms has an excellent safety profile. This protocol provides a reasonable alternative to pre-treating with aspirin and clopidogrel. The protocol is also particularly useful in patients with ruptured aneurysms or when the use of a stent was unexpected.

Disclosures

N. Chalouhi: None. M. Zanaty: None. R. Starke: None. P. Jabbour: None. D. Hasan: None.
O-028 Endovascular Treatment of Small-Unruptured Cerebral Aneurysms with Flow Diverters
Authors: Piotin M , Bartolini B , Redjem H , Pistocchi S , Blanc R
Published: July 2014

Purpose

To assess the safety and efficacy issues of Flow Diverters (FD) in the treatment of small unruptured cerebral aneurysms.

Methods

Retrospective review of a prospectively gathered database of endovascularly treated aneurysms since the introduction of FD. From September 2008 (when treatment aneurysms with FD was initiated at our institution) to January 2014, 519 small (<10 mm), unruptured aneurysms were treated by endovascular means. Four treatment modalities were individualised: simple coiling, balloon-assisted coiling, stent-assisted coiling and aneurysm neck coverage with FD.

Results

(87/519) 16.8% (mean sac size: 5.0 mm, 70.1.4% bifurcation) of aneurysms were simply coiled.

(189/519) 36.4% (mean sac size: 4.9 mm, 54.5% bifurcation) of aneurysms were coiled with balloon assistance.

(166/519) 32.0% (mean sac size: 6.1 mm, 75.3% bifurcation) of aneurysms were coiled with stent-assistance.

(77/519) 14.8% (mean sac size: 5.0 mm, 14.5% bifurcation) aneurysms were treated with FD.

Procedural perioperative and delayed (up to 180 days) permanent neurological complications were 0.0%, 4.0%, 10.1% and 3.1% respectively, with a marked trend for more complications with stent-assisted coiling (P = 0.0037). Total immediate aneurysm occlusion was obtained in 49.4% (43/87), 53.4% (101/189), 59.0% (98/166) and 3.9% (3/77) respectively, with a marked trend toward better occlusion with stent-assisted coiling technique (P < 0.0001). At a mean angiographic follow-up of 16 months for aneurysms treated with FD and 23 months for the others, total aneurysm occlusion was 59.2% (32/54), 70.4% (88/125), 85.4% (111/130) and 70.7% (41/58) respectively, with a trend toward better occlusion with stent-assisted coiling (P = 0.0011).

Conclusions

FD for the treatment of small-unruptured aneurysms confer a good safety profile that compares favorably with those of balloon-assisted technique, but are mostly indicated for sidewall aneurysms. Occlusion rates at follow-up are better with stent-assisted-coiling than FD but with higher morbidity.

Disclosures

M. Piotin: 2; C; Covidien, Stryker, Balt, MicroVention, Reverse Medical, Neuravi, Penumbra. 4; C; Lazarus Effect. B. Bartolini: 2; C; Covidien, Stryker, Balt, MicroVention, Penumbra. H. Redjem: 2; C; Covidien, Stryker, Balt, MicroVention, Penumbra. S. Pistocchi: 2; C; Covidien, Stryker, Balt, MicroVention, Penumbra. R. Blanc: 2; C; Covidien, Stryker, Balt, MicroVention, Reverse Medical, Neuravi, Penumbra. 4; C; Lazarus Effect.