bluuebunny/crossref_metadata_2025 huggingface dataset:
E-024 Meta-analysis of randomized intra-arterial thrombolytic trials in the treatment of acute stroke
Authors: Fields J , Khatri P , Nesbit G , Liu K , Barnwell S , Lutsep H , Clark W , Lansberg M
Published: December 2010

Background

Intra-arterial (IA) administration of tissue plasminogen activator (tPA) is an important therapeutic modality in the treatment of acute stroke. Three randomized, multicenter, placebo controlled trials have been performed evaluating IA thrombolytics within 6 h of onset of acute ischemic stroke; two of the trials were positive on some but not all functional end points and a third trial showed non-significant trends on all outcomes. We performed a meta-analysis to estimate with more precision the effect of IA tPA on several key clinical end points.

Methods

We evaluated the PROACT, PROACT II and MELT trial methodologies to assess for compatibility in study protocols and statistical analysis. Data were then abstracted from these three trials and statistical analysis was performed using RevMan (RevMan V.5.0, The Nordic Cochrane Centre, Cochrane Collaboration, 2008). The following end points were evaluated: modified Rankin Scale (mRS) ≤1; mRS≤2; National Institutes of Health Stroke Scale (NIHSS) score 0 or 1; 90 day mortality; and spontaneous intracerebral hemorrhage (SICH) within 24 h.

Results

Despite minor differences in protocols, the three trials appeared suitable for combined analysis. Functional outcomes were significantly improved by IA thrombolytic administration: IA thrombolytic treated patients were significantly more likely to have a mRS ≤1 (OR 2.0, 95% CI 1.1 to 3.6); mRS ≤2 (OR 1.7, 95% CI 1.0 to 2.9); and NIHSS score 0 or 1 (OR 2.4, 95% CI 1.3 to 4.4) at 90 day follow-up. There was no effect on mortality at 90 day (OR 0.84, 95% CI 0.5 to 1.5). The risk of SICH was significantly increased in the active treatment arms (OR 4.6, 95% CI 1.3 to 16).

Conclusions

Meta-analysis of the randomized trials assessing IA administration of thrombolytics demonstrates that all standard functional end points for stroke trials were substantially improved in the active treatment arms. Despite a significantly increased risk of intracerebral hemorrhage, there was no net effect on mortality. These results support endovascular treatment of acute ischemic stroke patients with intra-arterial lytics.
E-025 Transvenous embolization of cavernous carotid fistulas facilitated by a distal access catheter
Authors: Haithcock J , Toth G , Pride G
Published: December 2010

Introduction and purpose

Although transvenous embolization of indirect carotid cavernous fistulas (iCCFs) represents an effective treatment strategy, venous navigation related limitations can prevent access to the entire fistulous site, decreasing the probability of definitive occlusion. In such cases, more invasive access to the involved vein, such as open surgical exposure, direct puncture of the superior ophthalmic vein or direct access to the anterior portion of the cavernous sinus may be needed to achieve a definitive cure. We describe two cases in which a coaxial technique using a commercially available distal access catheter facilitated venous navigation from the common femoral vein, enabling definitive obliteration of the iCCF. Our purpose includes reporting of these cases, discussion of endovascular strategies and a review of the various venous routes of access to the cavernous sinus.

Materials and methods

We reviewed all recent endovascular procedures performed at our institution to identify two cases of iCCF in which a coaxial access technique using a commercially available distal access catheter was used to facilitate treatment. The procedural notes, hospital charts and imaging studies were reviewed to identify potential novel procedural details or problems related to this technique. Additionally, we reviewed the current medical literature related to endovascular iCCF embolization in order to complement our summary review of the various venous approaches employed for iCCF treatment.

Results

The coaxial technique using a distal access catheter to achieve fistula access from the common femoral vein facilitated complete iCCF obliteration in both of our cases, without any added periprocedural morbidity. The technique was straightforward, easily applied and greatly simplified transvenous embolization of the iCCF in both cases.

Conclusion

The distal access catheter was introduced as an adjunct device for mechanical thrombectomy procedures using the Merci embolectomy system by providing microcatheter support during clot retrieval and improved stability in tortuous arterial anatomy. Similarly, successful endovascular treatment of iCCFs from a transvenous approach also requires navigation through tortuous venous anatomy and enhanced microcatheter stability in order to achieve successful embolization of the fistula. A distal access catheter was used in two patients with iCCFs treated via a transvenous endovascular approach which greatly facilitated complete obliteration of the fistula in both cases. The use of a distal access catheter in mechanical thrombectomy procedures is well documented, and given the ease of use and compatibility with the various guiding catheters and microcatheters currently available, the distal access catheter will likely have an increasing role in other intracranial neurointerventional procedures.

Abstract E-025 Figure 1
E-027 Final results of a multicenter, prospective, long term coil embolization study
Authors: Paulsen R
Published: December 2010

Purpose

To design and set up an electronic database with longitudinal information on the use of bare platinum coils for the endovascular occlusion of cerebral aneurysms. We report the final analysis of the data.

Materials and methods

From 1 May 2004 to 10 July 2007, a global registry was conducted at 36 centers in the USA, Europe and Latin America. 303 patients were enrolled of whom 299 patients were treated with bare detachable platinum coils (mostly Trufill DCS Orbit coils) of various sizes, shapes and grades of softness. Acute as well as long term anatomical and clinical data were collected. Logistic regression analysis will be used to examine the association of selected patient characteristics to outcomes of recanalization, retreatment and stability of occlusion.

Results

313 aneurysms, ruptured or unruptured, were treated in the 299 patients. Follow-up data were available on 185 patients (including 10 reports of deaths); 32 patients returned for more than one visit; 140 (76%) had 3–6 months of follow-up, 63 (34%) had 1 year of follow-up and five (3%) had 2 years of follow-up.

This abstract reviews the status of 185 patients with follow-up data available at this time. Immediately postprocedure, the treating physicians reported achieving the desired level of occlusion in 167 (85%) of the treated and followed aneurysms: 114 (58%) aneurysms were completely obliterated, 40 (20%) residual neck, 23 (12%) residual aneurysm and 19 (10%) dog ear. Of 174 aneurysms with angiographic follow-up, 137 (79%) remained stable or improved, nine (5%) showed aneurysm regrowth, 26 (15%) compaction and two (1%) had migrated. At 3–6 months, 14 of the 174 (8%) aneurysms were re-treated.

Conclusion

These results confirm previous outcomes data of endovascular occlusion of cerebral aneurysms with Trufill DCS Orbit complex shaped detachable platinum coils. Complications related to the device were rare.
E-028 Stenting and angioplasty of a symptomatic long segment extracranial vertebral artery occlusion
Authors: Sivapatham T , Hussain M , Spiotta A , Gupta R
Published: December 2010

Introduction

We report a case of successful revascularization of a symptomatic long segment extracranial vertebral artery occlusion using stenting and angioplasty. A 55-year-old man with a history of tobacco abuse, hypertension and hyperlipidemia presented with dysarthria and diplopia that occurred 3 weeks earlier. The patient was noted to have bilateral vertebral artery occlusions on CT angiography and acute infarcts involving the posterior circulation on MRI. He was placed on dual antiplatelet therapy with aspirin 325 mg daily and clopidogrel 75 mg daily along with a lipid lowering agent. The patient had recurrent symptoms despite medical therapy. He was referred to our institution for further management.

Materials and methods

Cerebral angiogram revealed a total occlusion of the left vertebral artery and a long segment occlusion of the extracranial right vertebral artery that reconstituted via muscular branches and thyrocervical branches. The intracranial posterior circulation remained patent due to these collaterals. No posterior communicating arteries were present. After a detailed discussion regarding surgical and endovascular options, we proceeded with the endovascular approach.

The patient was placed under general anesthesia. A platelet aggregation panel prior to the procedure confirmed adequate platelet inhibition for both aspirin and clopidogrel. Intravenous heparin was administered to maintain an activated clotting time of 250–300 s throughout the procedure. A femoral artery approach was used and a 5 F diagnostic catheter was exchanged for a 6 F 90 cm Cook shuttle sheath that was positioned in the right subclavian artery for support. A 6 F Envoy guide catheter (100 cm length) was coaxially placed through the shuttle sheath into the stump of the vertebral artery.

A Rapid Transit microcatheter and 0.014 in Synchro-2 microwire were initially used to attempt navigation across the occluded segment but were unsuccessful. The wire was replaced with a 0.018 in V-18 microwire and we were able to navigate across the occlusion with this wire/catheter combination. The catheter was removed over a 300 cm Transend floppy exchange wire and a total of five drug eluting, balloon-mounted Xience V stents were deployed in a telescoping fashion from the mid-cervical vertebral artery to the vertebral artery origin.

Results

Post-stent angiography demonstrated good antegrade flow through the cervical vertebral artery. The patient recovered from anesthesia with no new neurologic deficits.

Conclusion

Revascularization of a long segment total occlusion of the extracranial vertebral artery can be performed safely using endovascular techniques in symptomatic patients.

Abstract E-028 Figure 1
E-003 Initial experience with a ‘timeout’ designed for neuroendovascular procedures
Authors: Wells K , Kapadia S , Cantrell B , Keigher K , Lopes D , Chen M
Published: December 2010

Introduction

Morbidity and mortality as a result of medical errors has become a significant health problem. As part of a national patient safety goal initiative, almost all medical centers have adopted measures to decrease the incidence of medical errors. In order to improve communication among members of the surgical team, a preoperative checklist is done prior to initiating any procedure (time out). The neuroendovascular patient undergoing an intervention such as cerebral aneurysm coiling and/or stenting, arteriovenous malformation embolization and carotid stenting presents unique challenges compared with body interventions or open neurosurgery cases. Some of these challenges include assessment of patient kidney function, contrast allergy, femoral/pedal pulses, need for ASA/Plavix and humanitarian device exemption (HDE) consents. The purpose of this study was to develop a ‘time out’ customized to neuroendovascular patients and test it in a clinical setting.

Materials and methods

We listed the most important safety factors involving neuroendovascular interventions and compared them to the standard open surgery ‘time out’ checklist. A specific neuroendovascular checklist was developed. We then in-serviced the staff of the neuro-angio suite which included six registered nurses, four radiology technologists and two endovascular surgeons to institute the preoperative checklist. The following is an abbreviated form of the neuroendovascular time out we implemented: What patient do we have? What procedure are we doing? Do we need any HDE/special consents (Enterprise, Neuroform, Wingspan, Research)? What is the assessment of access site and marking? Is the patient positioned correctly? Are there any precautions based on status or meds? Are ASA and Plavix required for the procedure; or other special medications? Are irrigation fluids required and available? Do we require any special implants, equipment, films? If so are they available? Are any antibiotics required? Is DVT prophylaxis indicated? After 3 months of clinical application of the neuroendovascular time out at RUSH University, the team was asked to respond to a self-assessment questionnaire.

Results

The neuroendovascular time out was applied in 152 cases over 3 months. In all cases the time out was completed before the procedure initiated. The answers to each time out were documented and incorporated to the patient's electronic medical record.

The answers from the self-assessment questionnaire were obtained from all the participating members of the endovascular team. The results revealed great acceptance to the concept of time out and 12/12 questionnaires agreed that the customization was more relevant to neuroendovascular patients. There was also unanimous opinion that the neuroendovascular time out has increased safety for our patients undergoing procedures.

Conclusion

The neuroendovascular time out is more relevant to cerebrovascular patients and proved to be valuable in a clinical setting.
E-036 Hemodynamic stability during carotid artery stenting under general anesthesia in elderly patients with a high grade carotid artery stenosis
Authors: Cho C , Park H
Published: December 2010

Purpose of study

During carotid artery stenting (CAS) under local anesthesia, hemodynamic instability (hypotension, bradycardia, etc) has been reported to occur. Hemodynamic instability during CAS under local anesthesia, especially in elderly patients, may be a risk factor for complications.

We evaluate the hemodynamic stability during CAS under general anesthesia in elderly patients with a high grade carotid artery stenosis.

Methods

15 CAS procedures were performed under general anesthesia using sevoflurane and nitrous oxide in oxygen in in 15 patients aged 65 years or older between November 2007 and February 2009. All CAS procedures were performed for high grade stenoses (>70% in NASCET criteria). Nine procedures were performed for symptomatic stenoses. Degree of systolic blood pressure change, hypotension and bradycardia during CAS were assessed.

Results

Mean age of patients was 69±3.2 years. Mean degrees of stenosis before and after CAS was 75.8±7.5% and 25.9±9.8%, respectively. No hypotension (systolic blood pressure <80 mm Hg) occurred during procedures, and transient bradycardia (heart rate <50/min) occurred in one patient (0.6%) during the procedures. Mean systolic blood pressure change was 35±11.9 mm Hg. No procedure was complicated by stroke during or after CAS.

Conclusion

General anesthesia using sevoflurane and nitrous oxide in oxygen depressed baroreceptor reflex sensitivity, induced hemodynamic stability during CAS and may decrease the rate of occurrence of complications in elderly patients with a high grade carotid artery stenosis.
E-037 Endovascular treatment of traumatic pediatric posterior circulation pseudoaneurysms
Authors: Farid H , Tatum J , Halbach V , Higashida R , Dowd C
Published: December 2010

Introduction and purpose

Traumatic intracranial aneurysms are rare and represent fewer than 1% of all intracranial aneurysms. They may develop as the result of blunt or penetrating head trauma and are associated with a significant mortality of up to 50%. Traumatic aneurysms typically involve the anterior circulation or the internal carotid artery at the level of the skull base. They rarely involve the posterior circulation. We present three pediatric patients with traumatic aneurysms in the posterior circulation and describe their clinical presentation, angiographic findings and clinical outcome after being treated by endovascular technique.

Materials and methods

We retrospectively reviewed the angiographic and clinical findings in three pediatric patients, aged 12 years and younger, with traumatic pseudoaneurysms occurring in the posterior circulation in a variety of locations: one in the basilar artery, one in the posterior cerebral artery and one in the superior cerebellar artery.

Results

Three patients with three posterior circulation pseudoaneurysms (two male patients and one female patient; aged 3–12 years) were admitted during the past 2 years. All three patients underwent endovascular coil embolization. No complications were noted from these procedures. All patients improved clinically after treatment.

Conclusions

Contemporary endovascular techniques can be used effectively to treat posterior circulation pseudoaneurysms in the pediatric population. Treatment efficacy may be improved if there are bony confines around the aneurysm or if therapy takes place in the subacute period, when the wall of the pseudoaneurysm has matured and stabilized.
E-038 Utility of Dyna CT in the evaluation and management of cranial and skull base arteriovenous fistulas
Authors: Gandhi D , Huang J , Gomez J , Kathuria S
Published: December 2010

Introduction

Intracranial dural arteriovenous fistulas (dAVFs) are comprised of pathologic, dural based shunts and account for 10–15% of all intracranial arteriovenous malformations. These lesions have complex anatomy that is best studied with conventional digital subtraction angiography (DSA). Conventional DSA is however limited by its planar imaging nature. A more detailed analysis of these lesions is now possible with cone beam CT. We present our initial experience with 10 patients of dAVFs studied with C arm CT.

Methods

This study includes 10 patients with intracranial and skull base dAVFs that were evaluated with conventional DSA and a C arm CT (Dyna CT) between January 2009 and February 2010 by one of the authors (DG). The DSA evaluation included selected catheter angiograms of bilateral common, internal, external carotid and vertebral arteries. Additional Dyna CT evaluation was accomplished while injecting diluted contrast into the dominant feeding artery. MPRs were performed by using an external postprocessing workstation (syngoXWorkplace; Siemens Medical Solutions) to produce section thickness of 0.2–0.5 mm. This study is a retrospective review of patient charts, imaging studies and DSA/C arm CT evaluations.

Results

C arm CT was successfully performed on all patients and provided excellent quality images. The anatomic understanding of the osteodural network, location of arteriovenous shunt and venous compartment was aided by Dyna CT and significantly added to the understanding of these lesions. In addition, there were additional findings noted on Dyna CT that had significant impact on management of four of 10 patients. The final management included endovascular treatment exclusively in 5/10, combination of embolization and surgery in 1/10 and embolization followed by gamma knife in 1/10. Three of 10 patients are being managed conservatively in view of Borden type 1 fistulae that were minimally symptomatic.

Conclusion

C arm CT is complementary to DSA in the evaluation of cranial and skull base dAVFs. In many patients, Dyna CT provides information that is difficult to obtain from conventional DSA. In our initial experience, Dyna CT had a significant impact in the management of these lesions.
E-004 Cranial dural arteriovenous fistulas: asymptomatic cortical venous drainage portends less aggressive clinical course
Authors: Strom R , Botros J , Refai D , Moran C , Cross D , Grubb R , Chicoine M , Rich K , Dacey R , Zipfel G , Derdeyn C
Published: December 2010

Objective

Cranial dural arteriovenous fistulas (dAVFs) with cortical venous drainage (CVD) (Borden type 2 and 3) are reported to carry a 15% annual risk of intracranial hemorrhage (ICH) or non-hemorrhagic neurological deficit (NHND). The purpose of this study is to compare the clinical course of type 2 and 3 dAVFs that present with ICH or NHND versus those that do not.

Methods

28 patients with type 2 or 3 dAVFs were retrospectively evaluated. CVD was classified as asymptomatic (aCVD) if patients presented incidentally or with pulsatile tinnitus or orbital phenomena. CVD was classified as symptomatic (sCVD) if patients presented with ICH or NHND. Occurrence of new ICH or new or worsening NHND between diagnosis and disconnection of CVD or last follow-up (if not disconnected) was noted. Overall frequency of events was compared using Fisher's exact test. Cumulative event free survival was compared using Kaplan–Meier analysis with log rank testing.

Results

Of 17 patients with aCVD, one (5.9%) developed ICH and none experienced NHND or death during the mean 4.1 years of follow-up. Of 11 patients with sCVD, two (18.2%) developed ICH and three (27.3%) suffered new or worsened NHND over the mean 2.4 years of follow-up. One of these patients subsequently died. Overall frequency of ICH or NHND was significantly lower in patients with aCVD versus sCVD (p=0.022). Respective annual event rates were 1.4% versus 19.0%. aCVD patients had significantly higher cumulative event free survival (p=0.0016).

Conclusion

Cranial dAVFs with aCVD may have a less aggressive clinical course than those with sCVD.
E-041 Combined endovascular embolization and surgical resection of a massive lumbosacral arteriovenous malformation in a patient with Cobb syndrome
Authors: Spiotta A , Hussain M , Sivapatham T , Masaryk T , Krishnaney A
Published: December 2010

Objective and importance

Cobb syndrome is a rare condition that includes a cutaneous nevus with an associated spinal vascular lesion at the same dermatome. We present a challenging case of a progressively symptomatic massive lumbosacral arteriovenous malformations (AVM) in a patient with Cobb's syndrome requiring a multimodality approach, including staged preoperative transarterial and transvenous endovascular embolization followed by surgical excision and wound reconstruction.

Clinical presentation

The patient is a 25-year-old man with a massive lumbosacral AVM with symptoms of congestive heart failure. Angiography demonstrated arterial feeders predominantly from the internal iliac, median sacral and lumbar segmental arteries.

Intervention

The patient underwent staged transarterial and transvenous endovascular embolization resulting in 90% reduction in the AVM size, followed by surgical resection of the lesion. The patient made an excellent recovery with improvement in his symptoms of congestive heart failure.

Conclusion

The treatment algorithm for massive AVMs must be individualized. A combination of staged embolization and subsequent surgery may be required to obtain a good result. Through this carefully planned multidisciplinary approach, a previously incurable lesion in this patient with Cobb syndrome was able to be treated successfully.

Abstract E-041 Figure 1
E-042 Incidence of very small ruptured aneurysms (<3 mm) in the stroke belt: a single center experience and outcome analysis
Authors: Turner R , Brothers M , Chaudry I , Turk A
Published: December 2010

Introduction

Very small aneurysms (<3 mm) have a low rate of spontaneous rupture, however when treatment is warranted, pose an increased risk of procedural complications, specifically intraprocedural rupture. Endovascular treatment of these aneurysms is controversial given the high complication rate, particularly intraprocedural rupture. However, there are patients who are better suited to endovascular occlusion due to clinical grade or comorbidities. We analyzed this series of patients to evaluate procedure safety and acute outcomes using this newer coil technology.

Methods

The MUSC endovascular registry is a prospective database with predefined parameters which tracks all diagnostic and endovascular interventions. A database query was performed to obtain all aneurysms measuring <3 mm. Immediate occlusion rates and procedural complications were evaluated for safety and efficacy. The most current clinical status of patients was also evaluated for outcome analysis.

Results

15 patients with 16 aneurysms underwent coil embolization between August 2009 and February 2010, representing 17.2% of all aneurysms coiled during that period. 11 of the 16 aneurysms (69%) were ruptured, four (25%) were unruptured aneurysms in patients with a history of subarachnoid hemorrhage (SAH) and a previously treated ruptured aneurysm and one patient was unruptured with a strong family history of SAH. Mean length of the largest diameter was 2.7 mm (range 2–3 mm). All but one aneurysm achieved complete occlusion acutely, and high packing densities were obtained in all aneurysms. Eight aneurysms (seven ruptured) were treated with a balloon assist technique and were not associated with any adverse events. Four aneurysms (one ruptured) were stent assisted, with two of the procedures (both unruptured) were complicated by intraprocedural rupture. Both patients were discharged from the hospital within 4 days of the procedure with no clinical deficits and a modified Rankin scale (mRS) score of 0. Four aneurysms (three ruptured) were treated without adjunctive devices and one patient (ruptured) had an intraprocedural rupture without clinical consequence and was discharge on hospital day 14. Overall, 12 patients had an mRS score of 0 and one patient a score of 1. One patient has an mRS score of 4 but presented with a Hunt and Hess score of 5 with minimal improvement. One patient is currently completing his acute treatment.

Conclusions

Very small aneurysms account for a significant number of aneurysms treated at our institution. Complete occlusion is achievable in a large percentage of these aneurysms but they are associated with a higher procedural complication rate. In patients with ruptured (and unruptured) aneurysms, clinical outcomes were very good. Long term outcomes and follow-up are forthcoming.
E-043 Novel use of the Penumbra Aspiration System in three cases of severe dural venous sinus thrombosis
Authors: Morgan S , Chaudry I , Turk A , Turner R
Published: December 2010

Introduction

Dural sinus venous thrombosis is a rare but potentially devastating disease. Current therapies include intravenous heparin, direct mechanical thrombectomy and local chemical thrombolysis. Despite aggressive management of this disease with these therapeutic interventions there are treatment failures that may be amenable to endovascular intervention. To date there is no endovascular device made specifically for this purpose.

Methods

Three patients presented with neurological symptoms related to increased intracranial pressure. Non-invasive imaging demonstrated cerebral sinus occlusion. All patients were initially treated with intravenous heparin. The first patient had bilateral transverse and sigmoid sinus and superior sagittal sinus thrombosis, the second had left transverse and sigmoid sinus thrombosis and the third patient had thrombosis of the left transverse sinus which extended into the sigmoid sinus and internal jugular vein. All patients were neurologically deteriorating at the time of intervention and had developed hemorrhagic strokes despite aggressive heparinization.

Results

All of the patients were successfully revascularized angiographically with the Penumbra Aspiration System in combination with local chemical thrombolysis. The first patient had end stage renal disease and significant comorbidities and eventually succumbed to multiorgan failure secondary to her pre-existing disease. The second patient developed leg weakness prior to the thrombolysis which progressed to paraplegia post-thrombectomy. Her leg strength was improving at discharge (4/5) and she was able to ambulate with assistive devices. She lives at home 2 months post-thrombectomy and ambulates without assistance. The third patient required hemicraniectomy for left parietal hemorrhage. She was discharged to rehab and returned for follow-up at 6 months with minimal word finding difficulties and otherwise neurologically intact. Both survivors were converted to warfarin therapy on discharge.

Conclusion

Successful revascularization was achieved in all three patients using a combination of thrombectomy with the Penumbra Aspiration System and local thrombolysis. All patients were severely injured secondary to sinus thrombosis related strokes; however, aggressive escalation of therapy along with successful revascularization resulted in very good long term outcomes in two patients. To our knowledge these are the first of such cases reported to use the Penumbra Mechanical thrombectomy device to re-canalize the dural venous sinus system.
E-044 Impact and outcomes of physiologic imaging for acute stroke patient selection for endovascular therapy
Authors: Turk A , Chaudry I , Turner R
Published: December 2010

Background

There are more than 700 000 new or recurrent strokes that occur in the USA each year. The majority are due to acute cerebral ischemia. Limited clinical data exist on the practical utilization of perfusion imaging patient based selection and outcomes.

Methods

At a state university academic institution, the number of stroke patients treated between 9/2006 and 12/2009 were recorded. They were split into two groups. The first group were those selected and treated historically by the time from symptom onset and clinical presentation (9/2006–12/2007). The second group were those selected through the Brain Attack Triage system triaging system utilizing clinical presentation National Institutes of Health Stroke Scale (NIHSS) in addition to standard anatomic and perfusion CT imaging (1/2008–12/2009), irrespective of time from symptom onset. The clinical and angiographic outcomes will be reported only for those utilizing the perfusion based approach because of the limited number of patients prior to this. A retrospective chart review was performed to identify age, concurrent administration of intravenous tissue plasminogen activator (IV tPa), time to treatment, presenting NIHSS, 90 day modified Rankin scale (mRS) and angiographic recanalization rates.

Results

The number of patients treated from 9/2006 to 12/2007 was 12 and from 1/2008 to 12/2009 was 53. The average patient was 65 years old with a median of 66 years. IV tPA was concurrently administered in 18 cases. Occluded vessel locations were: basilar (n=8); internal carotid artery (n=13); middle cerebral artery (n=31); and posterior inferior cerebellar artery (n=1). Average and median NIHSS were 17.15 and 17, respectively. The average time to treatment was 10.36 h and the median was 6.13 h. Recanalization rates were: TIMI 1: 4%, TIMI 2: 36% and TIMI 3: 60%. 90 day mRS scores were: mRS 0–2: 37%, mRS 3: 17%, mRS 4: 13%, mRS 5: 10% and mRS 6: 23%.

Conclusion

The use of physiologic imaging for patient triage of acute ischemic stroke patient selection for intervention is feasible and safe. The clinical application of this approach can significantly impact the number of patients amenable to endovascular therapies.
E-045 The effect of liquid embolic agents on gamma knife radiosurgery dosimetry for arteriovenous malformations
Authors: Jiang T , Mamalui-Hunter M , Rich K , Dryzmala R , Derdeyn C
Published: December 2010

Purpose

The effectiveness of gamma knife stereotactic radiosurgery to obliterate brain arteriovenous malformations (AVMs) may be diminished by the preoperative adjunctive use of endovascular liquid embolic agents. The purpose of the present investigation was to determine if commercially available liquid embolic agents reduce the radiation dose to the target owing to attenuation of the Co-60 beam.

Method and materials

(1) The apparent linear attenuation coefficients for 120 keV to 140 keV x-rays in the embolized regions were retrieved from CT scans for several patients with AVM malformations who had undergone embolization procedures with liquid embolic agents for the purposes of reduction in nidal volume. Based on these coefficients and our virtual model of gamma knife with basic ray tracing, we obtained the path lengths and densities for the embolized regions. The attenuation of Co-60 beams was then calculated for various sizes and positions of AVM embolized regions and the number of beams used for treatment. (2) Published experiments for several high atomic number materials were used to estimate the effective Co-60 beam attenuation coefficients for N-butylcyanoacrylate (n-BCA, suspended in ethiodized oil) and ethylene-vinyl alcohol copolymer (EVOH, with suspended micronized tantalum powder) used in the AVM embolizations. The dose reduction during gamma knife radiosurgery was calculated based on the Co-60 energy attenuation coefficient. (3) Dose measurements were obtained in a phantom study with EVOH to confirm the estimates generated in the theoretical model described in (2) above.

Results

Based on apparent CT (keV) attenuation coefficients, the cumulative effect of either of the embolic agents decreased the dose delivered in gamma knife radiosurgery from −8 to −15% in a theoretical mod. Using the effective attenuation coefficient for Co-60 energies in the dose calculation yielded a 0.2% dose reduction per beam and less than 0.01–0.2% dose reduction in total. These theoretical results were validated in a phantom study.

Conclusion

Dose reduction due to attenuation of the Co-60 beam by the AVM embolization material is negligible for both n-BCA and EVOH, owing to the high energy Co-60 beam.
E-046 Endovascular and microsurgical management of pericallosal aneurysms
Authors: Hui F , Schuette A , Spiotta A , Hussain M , Moskowitz S , Cawley C
Published: December 2010

Pericallosal aneurysms represent a relatively infrequent cause of subarachnoid hemorrhage (SAH). In the ISAT trial, there were 95 reported pericallosal aneurysms out of 2143 treated aneurysms, thus comprising 4.4% of aneurysms. While the ISAT broadly concluded that there was a benefit of treating ruptured anterior circulation aneurysms, studies comparing endovascular and microsurgical repair in anterior circulation aneurysms of a specific location are few. In this study, we reviewed the aneurysm databases from two institutions spanning 1999 to 2009, identifying 4456 aneurysms of which 88 were pericallosal aneurysms. Patients were classified according to presence or absence of SAH, presentation grade with Hunt and Hess scores and modified Fisher grade. Aneurysm size and method of treatment was recorded. Outcomes at latest possible follow-up date were recorded using the modified Rankin Scale (mRS). Recurrences were also noted.

Statistical analysis of outcomes of aneurysm treatment were recorded comparing microsurgical and endovascular repair in both ruptured and unruptured populations.

Intraprocedural rupture rates and outcome measures were compared, with craniotomy associated with greater probability of resulting in lower mRS in the acute setting (p=0.048).
E-048 Carotid blowout syndrome: emergent endovascular management by stenting
Authors: Tisnado J , Champlain M Des , Sydnor M , Komorowski D , Ehlenberger C , Fox W
Published: December 2010

Introduction

Carotid blowout syndrome (CBOS) is a catastrophic emergency associated with high morbidity and mortality. The usual causes are postoperative, inflammation, traumatic, and head and neck tumor invasion. The conventional surgical management is fraught with high morbidity, mortality and complication rates and is ineffective in some cases. This includes carotid artery and/or branch ligation. Carotid artery bypass can be performed with limited success. With the advent of uncovered and covered stents, the emergent management of CBOS has improved and, perhaps, at this time, a desperately fatal disease can be managed with temporary success.

Materials and methods

During the past 3  years, we have studied five patients (men and women of middle and advanced age) with CBOS of different etiologies, who were considered difficult or not manageable by emergency surgery. Insertion of different types of both uncovered and covered stents, both self-expanding and balloon expandable was performed: Gore Viabahn Endoprosthesis, iCast (Atrium) covered stent, Fluency Plus Stent-Graft (Bard), Wallstent (Boston Scientific) and Protégé (Bard).

Results

The procedures were done in the interventional radiology suite and were successful in temporarily managing the CBOS. No major complications related to the procedures were encountered. No arterial rupture, occlusion, thrombosis, stroke or infection resulted in a short follow-up.

Conclusions

Emergent insertion of covered and uncovered stents, self-expanding and balloon expandable, is a safe, effective and easy way to temporarily manage CBOS. A longer follow-up and more patients are necessary to assess the long term role of stenting in CBOS.
E-052 Robotic digital subtraction angiography systems within the hybrid operating room
Authors: Murayama Y , Ishibashi T , Ebara M , Ikeuchi S , Takao H , Arakawa H , Kato M , Kobayashi N , Abe T
Published: December 2010

Objective

The authors describe the experience of robotic digital subtraction angiography (DSA) system in the hybrid operation room (OR)

Methods

A newly designed robotic DSA system (Artis zeego; Siemens AG, Erlangen, Germany) was installed in one of the hybrid OR. The system consists of a multi-axis robotic C arm and surgical OR table. In addition to conventional neuroendovascular procedures, the system was used as an intraoperative imaging tool for various neurosurgical procedures such as aneurysm clipping or spine instrumentation.

Results

501 neurosurgical procedures were successfully conducted in the hybrid OR using robotic DSA. During surgical procedures such as aneurysm clipping or arteriovenous fistula treatment, intraoperative two-dimensional/three-dimensional angiography and C arm based CT images (Dyna CT) were easily performed without moving the OR table. In addition, newly developed virtual navigation software (i-guide) can be used in the frameless navigation and access to deep seated intracranial lesions or needle placement.

Conclusion

The newly developed robotic DSA system provides safe and precise treatment in the field of endovascular treatment and neurosurgery.
E-056 Endovascular treatment of medically refractory cerebral vasospasm following aneurysmal subarachnoid hemorrhage
Authors: Hetts S , Jun P , Ko N , English J , Dowd C , Higashida R , Halbach V
Published: December 2010

Background and purpose

Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (SAH) is a significant cause of morbidity and mortality. We review our experiences using percutaneous transluminal angioplasty (PTA) and intra-arterial (IA) verapamil infusion for treating medically refractory cases.

Materials and methods

Retrospective review of SAH patients admitted from July 2003 to January 2008.

Results

Of 546 patients admitted with SAH, 231 patients (42%) developed symptomatic CV and 189 patients (35%) required endovascular therapy. A total of 346 endovascular sessions were performed consisting of a single angioplasty, 286 IA verapamil infusions and 59 combined therapies. PTA was performed on 151 vessel segments and IA verapamil infused in 720 vessel segments. IA verapamil doses ranged from 2.0 to 30.0 mg per vessel segment and 3.0 to 55.0 mg per treatment session. Repeat treatments were necessary in 182 patients (96%) for persistent, recurrent or worsening CV. There were six treatment related complications (1.7%) of which two (0.6%) resulted in clinical worsening. No deaths were attributable to endovascular therapy. At follow-up, 115 patients (61%) had a good outcome and 55 patients (29%) had a poor outcome. Sixteen patients died from causes related to SAH while three died from other medical complications.

Conclusion

Endovascular treatments are an integral part of managing patients with medically refractory CV. In our experience, PTA and IA verapamil are safe with a very low complication rate but further studies are required to determine appropriate patient selection and treatment efficacy.
E-057 Endovascular management of pediatric aneurysms
Authors: Saleh E , Dawson B
Published: December 2010

Object

Although the general principles of endovascular aneurysm treatment in adults hold true in children, these young patients pose unique challenges: small anatomy, longer life expectancy, associated conditions and unique morphological characteristics of the aneurysms.

A few publications in literature have addressed the role of endovascular treatment for pediatric aneurysms. These include series by Agidet al(2005) revisiting the Toronto series (Laughlinet al1997), Lasjauniaset al(2005) updating the Bicêtre series (Lasjauniaset al1997) and Naderet alpresenting the San Francisco series (2006). In their conclusions, the authors of the former two publications favored endovascular treatment over microsurgery. On the other hand, the authors of the later publication favored microsurgery over endovascular treatment.

The authors reviewed Louisiana State University experience regarding endovascular treatment of pediatric aneurysms focusing on outcomes.

Methods

A retrospective chart review of children under 18 years of age who underwent endovascular treatment for intracranial aneurysms between 2000 and 2009 in our institution was undertaken. 12 patients harboring 17 aneurysms were identified. The patients ranged in age from 17 months to 17 years. Complete aneurysm obliteration following endovascular treatment was 90%. Our results showed unique features for pediatric aneurysms compared with adult aneurysms. There was no intraoperative mortality.

One aneurysm recurred (5% recurrence rate among total number of aneurysms). Six months after treatment, a control angiogram showed that the coils displaced towards the dome of the recurred aneurysm. This recurrence occurred before the introduction of the hydro coils. One patient died during the postintervention period (8% recurrence rate among total number of patients).

Outcomes were better in anterior circulation aneurysms than in posterior circulation lesions. We had no mortality, morbidity or disability in the anterior circulation aneurysm group. In the posterior circulation group, there was one death representing 14% of the nine patients with aneurysms in this group. One recurrence occurred in the posterior circulation group representing 11% of the nine aneurysms in this group. The follow-up of all patients ranged from 2 to 8 years.

Conclusion

Endovascular treatment of pediatric intracranial aneurysm is safe and efficacious. The endovascular treatment in many instances provides less morbidity and mortality for treatment of pediatric aneurysms in inaccessible or eloquent locations than microsurgical clipping. The result of endovascular treatment depends on the location of the aneurysms and the underlying pathology. We advocate a multidisciplinary approach when choosing the therapeutic modality for treatment of pediatric aneurysms.
E-059 A Novel approach for carotid sacrifice using temporary balloon occlusion and Onyx in a porcine model
Authors: Sivapatham T , Teng Q , Spiotta A , Hussain M , Moskowitz S , Hui F
Published: December 2010

Introduction

Carotid sacrifice is a valuable technique in the treatment of giant internal carotid artery aneurysms, carotid cavernous fistulae and carotid blowouts. With detachable balloons no longer available in the USA, most neurointerventionalists have relied on coil embolization as their primary means for carotid sacrifice, a procedure that can be lengthy and expensive. We describe a new technique for carotid sacrifice using temporary balloon occlusion of the carotid artery while embolizing the artery with Onyx in a porcine model.

Materials and methods

Following strict animal laboratory protocols, a total of 10 vessels were embolized in four pigs. The pigs were placed under general anesthesia and continuously monitoring by the animal laboratory veterinary staff. Access into the common femoral artery was gained using a micropuncture kit, and a 7 F sheath was placed. A 7 F guiding catheter was advanced over a 0.035 inch glidewire under fluoroscopic guidance into the right or left common carotid artery. A double Tuohy–Boorst was attached to the hub of the guiding catheter. An over the wire balloon was placed through one side port of the Tuohy–Boorst and advanced over a 0.010 inch microwire into the common carotid artery. An Onyx compatible microcatheter was then advanced through the second side port of the Tuohy–Boorst over a 0.010 inch microwire to a position adjacent or just distal to the balloon. The balloon was inflated and contrast injected through the guide catheter to confirm complete occlusion of flow. Onyx was then slowly injected under blank roadmap guidance into the common carotid artery through the microcatheter until a dense Onyx cast was visualized. Once the desired result was obtained, the microcatheter was removed and then the balloon was deflated and removed under fluoroscopic guidance. Follow-up angiography was performed. In four vessels, one or two coils were detached through the microcatheter, distal to the balloon, prior to Onyx embolization. In two vessels, the Ascent balloon catheter was used and Onyx embolization done directly through the balloon catheter.

Results

Successful occlusion of the carotid artery was obtained in eight of 10 vessels using the techniques described above. In the two unsuccessful vessels, we were able to identify deficiencies in our technique that led to the failures (premature removal of the balloon prior to formation of a dense Onyx cast in one vessel and detachment of a single coil as opposed to two coils in the other vessel).

Conclusion

Carotid sacrifice using Onyx with temporary balloon occlusion is a safe and effective technique, and can be performed more rapidly than the traditional method of coil embolization.
E-062 True aneurysms of the posterior communicating artery: a systematic review and meta-analysis of individual patient data
Authors: He W , Gandhi C , Quinn J , Karimi R , Catrambone J , Prestigiacomo C
Published: December 2010

Introduction

The term ‘true’ posterior communicating artery (PCoA) aneurysm refers to an aneurysm that originates from the posterior communicating artery itself. Over the past decades, an increasing number of this type of posterior communicating artery aneurysms have been reported. We systematically reviewed all of these published data and conducted a meta-analysis on these individual patient data.

Method

A meta-analysis of individual patient data was conducted.

Results

Pooled data demonstrated that ‘true’ PCoA aneurysms represented about 1.3% (95% CI 0.8% to 1.7%) of all intracranial aneurysms and 6.8% (95% CI 4.3% to 9.2%) of all PCoA aneurysms. Mean age was 53.5 (53.5±15.4) years and ranged between 23 and 79 years. 49 of these reported aneurysms had the ruptured status, 44 (89.8%) were reported as ruptured and four (10.2%) were reported as unruptured. There were no significant differences in ruptured status between age (p=0.321), aneurysm side (p=0.537) and shape (p=0.408). No significant differences in complication rates were found between the different ruptured status (p=0.27) or operative modalities (p=0.878). Mean ages of those patients who had no complications and those who had complications were 53 (53±2.59) versus 53.2 (53.2±5.02) years (p =0.972).

Conclusion

We concluded that ‘true’ PCoA aneurysms represent about 1.3% of all intracranial aneurysms and 6.8% of all posterior communicating artery aneurysms. ‘True’ PCoA aneurysms are more prone to rupture compared with their counterpart junctional aneurysms. When surgical management is indicated, care should be taken in choosing the operative approach to avoid oculomotor nerve damage and to preserve perforating branches as much as possible. A good understanding of the location and configuration of the aneurysm neck before surgical treatment is critical in successful treatment of these lesions.

Abstract E-062 Figure 1