bluuebunny/crossref_metadata_2025_split huggingface dataset:
E-001 Utility of flexible guide catheter in assisting transvenous superior ophthalmic vein catheterization and embolization of difficult to treat carotid–cavernous/orbital fistulas
Authors: Gandhi D , Kathuria S , Subramanian P , Miller N , Huang J 
Published: December 2010

IntroductionDural type fistulas of the cavernous sinus are complex lesions; transvenous embolization is often favored but may be difficult to accomplish if there is thrombosis, stenosis or occlusion of the drainage pathways. Surgical access to the superior ophthalmic vein (SOV) is very helpful in case of difficult endovascular access to the cavernous sinus. However, it is associated with a small but additional risk. This includes inability to cannulate the SOV or treat the fistula and less commonly intraorbital hemorrhage. With the availability of newer, flexible, distal access guide catheters, these difficult to treat cases could possibly be treated using exclusively endovascular approach.Materials and methodsDuring the past 2 years, eight patients with symptomatic cavernous sinus fistulae were endovascularly treated by one of the authors (DG). Three of the seven lesions were considered difficult to treat using transvenous access on account of thrombosis/occlusion of the inferior petrosal sinus and presence of unfavorable angle and/or severe stenosis at the junction of the SOV with the angular vein. One of three patients had a previous failed attempt at embolization using the angular/facial vein approach. Embolization was performed in all three patients using the middle temporal vein (2/3) or facial/angular vein (1/3), with flexible, distal access guide catheters.ResultsSuccessful catheterization of the SOV was facilitated using a combination of flexible distal access catheter (neuron or Merci distal access catheter) and a microcatheter. The flexible, guide catheters could be advanced very distally and just short of the junction of the angular vein and SOV (1/3) and supraorbital vein and SOV (2/3). This provided a stable platform and enhanced the microcatheter navigation into otherwise difficult to access SOVs. All lesions were successfully treated with this approach.ConclusionDistal access flexible guide catheters can be advanced across tortuous venous anatomy and can even reach just short of the SOV. This helps in providing a markedly stable platform and helps superselective microcatheterization of the SOV. With the help of these newer guide catheters, many of the difficult to treat carotid–cavernous fistulas could possibly be treated using an exclusive endovascular approach thereby avoiding the need for direct surgical exposure of the SOV.
E-012 Six year single center experience with the treatment of spinal dural fistulae
Authors: Chaudhary N , Gemmete J , Pandey A , Ansari S , Thompson B 
Published: December 2010

Introduction and purposeSurgical disruption has been the traditional method for treatment of spinal dural fistulae. Currently the natural history of spinal dural fistula is not clearly understood. There are a few case series reported in the literature documenting successful endovascular treatment of spinal dural fistula with n-butyl cyanoacrylate (n-BCA) liquid embolic material. A relatively new liquid embolic agent ethylene vinyl alcohol (Onyx) has been used extensively in the endovascular treatment of cerebral arteriovenous malformation and dural arteriovenous fistula. The first application of Onyx in the endovascular treatment of a spinal dural fistula was reported in the literature in 2003. An additional three cases of spinal dural fistula treated successfully with Onyx were reported in 2009. We present our experience with endovascular treatment of spinal dural fistula using n-BCA and more recently Onyx.Materials and methodsWe performed a retrospective review of all spinal dural fistulae cases that were treated at our institution from February 2004 to February 2010. Patient chart review, outpatient clinic follow-up letters and imaging review formed the retrospective analysis for the identified group of patients. 14 patients were identified with a spinal dural fistula. There were nine men and five women in the cohort. The age ranged from 16 to 81 years (mean 57 years). 13 were confirmed on digital subtraction spinal angiography (DSA) and one was negative on DSA.Results14 cases of spinal dural fistulae were treated. Three cases had to undergo surgical disruption due to the proximity of the anterior spinal artery to the arterial feeder to the fistula. All surgical cases were marked with coils in the anterior division of the intercostal artery to facilitate level identification. The 11 patients treated by endovascular embolization had a total of 14 procedures. Onyx was used as the liquid embolic agent in four cases while seven endovascular embolizations were performed utilizing n-BCA and coils. There were no procedure related complications associated with endovascular treatment. The mean follow-up of the cohort was 15 months (range 10 days–52 months). Nine of the 14 cases treated had symptomatic improvement and five were stable after treatment. All of the cases treated with Onyx had marked improvement in clinical symptoms.ConclusionEndovascular treatment of spinal dural fistula with liquid embolic agents is safe and effective. Surgical disruption should be performed when endovascular treatment risks iatrogenic injury or is not technically possible. Onyx may be an alternative to n-BCA when encountering inaccessible arterial feeders due to anatomic tortuosity. Utilization of the unique properties of Onyx may allow the safe treatment of spinal dural fistulae from a relatively proximal location.
E-013 Novel dual approach treatment of an internal carotid artery traumatic pseudoaneurysm
Authors: Turk A , Vandergrift A , Chaudry I , Turner R 
Published: December 2010

BackgroundTraumatic pseudoaneurysm formation related to transection of the internal carotid artery is an uncommon injury associated with skull base fractures. Rarely these aneurysms can extend through the fracture site and into the spheoid sinus. While stenting is a documented approach for addressing the vascular injuries, it is of limited use in treating aneurysms that project into the paranasal sinuses. Standard coiling is also of limited utility due to the lack of surrounding structures for support and, therefore, is prone to certain recurrence. Due to the curvature of the carotid siphon and the close proximity of the ophthalmic artery, placement of a covered stent is not feasible with current technology. The use of flow diverting devices may be beneficial but are not commercially available at this point and the long term implications are not fully understood. We present a novel method of combined endoscopic and endovascular techniques for treating these dangerous lesions.Materials and methodsA 23-year-old woman involved in a motor vehicle accident with traumatic brain injury began experiencing epistaxis 3 weeks after her injury. The ENT service felt the source to be related to the left posterior nasal septum and embolization was requested. Diagnostic cerebral angiography revealed a 5 mm pseudoaneurysm projecting from the internal carotid artery into the sphenoid sinus. The distal internal maxillary artery was unremarkable but was embolized due to continued concern for a septal source of epistaxis. The next day the aneurysm was coiled with balloon assistance with good immediate angiographic result. The patient was taken the following day to the operating room and the sphenoid sinus was endoscopically opened, packed with denuded nasal mucosa harvested from the nasal cavity and reinforced with fat and then sealed with a bone fragment. The next day the patient was loaded with Plavix and aspirin, and a Neuroform stent was placed across the injured vascular segment and aneurysm neck.ResultsThe aneurysm was angiographically well treated without residual during the initial coil procedure. There was irregularity of the carotid artery adjacent and distal to the aneurysm, likely representing further regions of injury. Surgically reinforcing the sphenoid sinus did not alter the angiographic appearance of the aneurysm. Placement of a stent across the aneurysm and adjacent areas of injury did not result in any acute angiographic changes. The patient did not suffer any adverse neurologic sequelae. Follow-up angiography is pending and will be presented if available.ConclusionTraumatic pseudoaneurysms projecting into the paranasal sinuses can be safely and perhaps more efficaciously treated with a combined endoscopic and endovascular approach.
E-019 Novel bioactive coil with modified PGLA
Authors: Kan I , Yuki I , Murayama Y , Vinuela F , Kim R , Zhang B , Wu B , Vinters H , Vinuela F 
Published: December 2010

PurposeNovel Bioactive Coil with modified PGLA was developed to further improve biological reaction induced by currently available PGLA coils.MethodPrototype coil materials were prepared by coating the currently available PGLA coils (matrix coil) with chemically modified PGLA. A total of 12 side wall aneurysms were surgically created in six swine. Four aneurysms were treated with Novel Bioactive Coil, four aneurysms were treated with 90/10 PGLA coils and four aneurysms were treated with bare platinum coil (Gugliemi Detachable Coils), respectively. All animals were kept alive for 14 days after the procedure. Histologic as well as immunohistochemical analyses were performed on each harvested sample.ResultsMacroscopic findings showed that significantly advanced thrombus organization was observed in the Novel Bioactive Coil group compared with the PGLA coil group and the bare platinum coil group. The granulation tissue induced by Novel Bioactive Coil was characterized by its intensive migration of multinuclear giant cells, profound microvascular proliferation and vacuole formation around the coil materials. Qualitative histological analysis showed that Novel Bioactive Coil elicited the most prominent macrophage expression, followed by PGLA coils and bare platinum coil.ConclusionNovel Bioactive Coil has a potential to elicit more accelerated thrombus organization compared with currently used coil materials, including bare platinum coil and PGLA coil.Abstract E-019 Figure 1
E-002 Initial experience with the Penumbra stroke system for recanalization of large vessel occlusions in acute ischemic stroke
Authors: Menon B , Hill M , Eesa M , Modi J , Bhatia R , Wong J , Hudon M , Morrish W , Demchuk A , Goyal M 
Published: December 2010

BackgroundThe Penumbra system is a newly approved mechanical device for the treatment of acute stroke designed for better and faster recanalization. We describe our initial experience with the use of this device.MethodsWe studied 27 consecutive patients with acute ischemic stroke from January 2009 to October 2009 at our stroke centre. The primary outcome was the degree of reperfusion (TIMI grade 2/3) at end of the procedure. Secondary end points were the proportion of patients who achieved a modified Rankin Scale (mRS) ≤2 at 3 months, all cause mortality and intracerebral hemorrhage (ICH) on non-contrast CT at 24 h. Procedural complications such as vascular perforations, vasospasm, dissection, distal embolization and groin complications were recorded.Results27 patients (13 men, mean age 61 years) were treated during the period January–October 2009. Median National Institutes of Health Stroke Scale on admission was 18 (range 3–32), median Alberta Stroke Program Early CT Score on non-contrast CT at admission was 8 (range 5–10) and median onset to intra-arterial treatment time was 192 min. 22 (81%) patients had anterior circulation strokes. 17 (63%) had intravenous tissue plasminogen activator initiated prior to angiography. 85% (23/27) patients achieved TIMI 2/3 grade reperfusion at completion of the procedure. 48% (13/27) patients had mRS ≤2 at the 3 month follow-up. Procedural complications included vasospasm (1/27), distal emboli (13/27) and ICH (seven HI1, one PH1 and one PH2). All cause mortality was 19% (5/27).ConclusionsHigh reperfusion rates and good clinical outcomes are achievable with the Penumbra system. Complication rates are comparable with the previously published literature.
E-021 Percutaneous vertebroplasty for osteoporotic fractures: experience with high viscosity cement using a hydrolic injection device, the ‘CONFIDENCE’ system
Authors: Georgy B 
Published: December 2010

PurposeVertebroplasty is a widely used technique to treat painful osteoporotic vertebral compression fractures but precise control of cement delivery is necessary to minimize the risk of cement leakage. The study is conducted to assess the clinical feasibility of performing vertebroplasty on osteoporotic compression fractures using an ultraviscous cement injected by a hydrolic device, CONFIDENCE Vertebral Augmentation System, to further control cement deposition.Material and methodA retrospective evaluation of a series of 94 consecutively treated patients was identified for the review. There were a total of 163 levels which ranged from T3 to L1 vertebral bodies. The degree of leakage, seen in the postoperative films, was assessed at each treated level using a strict 4 point scale (none, minimal, moderate, severe). The pattern of any observed leakage was also characterized as: distal, venous, paravetebral or epidural.ResultsPreoperatively the mean degree of vertebral collapse was 29%. A bipedicular approach was used for 82% (133/163) levels and unipedicular in 18% (30/163). There was no leakage in 50%, minimal leakage in 42% and moderate leakage noted in 8% of cases. Both unipedicular and bipedicular approaches showed leaks in 50% of cases. The most frequent pattern of leak was venous indicated in 52% of leaks, the adjacent disc in 46% and paravertebral in 5%. The pattern of leakage was always limited to one region except in two cases. There were no symptomatic leaks that required surgical intervention.ConclusionsVertebroplasty in osteoporotic fractures using a highly viscous cement that can be safely controlled and injected via a hydrolic system can be performed safely without significant complications.
E-022 Single institutional experience with placement of a compliant guide catheter into extremely distal locations within the intracranial and extracranial vasculature to facilitate treatment of various neurovascular pathologies
Authors: Gemmete J , Chaudhary N , Pandey A , Thompson B , Ansari S 
Published: December 2010

Introduction and purposeAccess to the intracranial pathology through tortuous vasculature has often been the limiting factor in treating certain patients. To address this issue, the 6 French Neuron (0.053 inches) delivery catheter (Penumbra Inc, Alameda, California, USA) was developed to provide greater proximal guide support and enable distal microcatheterization of the intracranial vasculature. A few articles have described the technique but guide positions in these publications were below the level of the dura. The purpose of this paper is to describe our experience with very distal placement of the guide catheter within the intracranial and extracranial vasculature enabling treatment of various neurovascular pathologies.Materials and methodsIn 12 patients, attempts were made to initially treat the neurovascular pathology with a standard guide catheter and microcatheter but they were unsuccessful either due to tortuous supra-aortic, cervical, extracranial or intracranial vasculature. The 6 F Neuron delivery catheter was substituted through a 6 F sheath for greater distal purchase and support.ResultsThe 6 F Neuron guide catheter was delivered in very distal vascular locations providing excellent support for advancement of the microcatheter and treatment of the lesion. The guide catheter was positioned in the following locations for treatment: origin of ophthalmic artery, M1 segment, M2 segment, A1 segment, P1 segment, basilar artery, origin of the anterior inferior cerebellar artery, distal internal maxillary artery, distal occipital artery, distal superficial temporal artery, cavernous sinus and distal superficial temporal vein. Three patients were treated for carotid cavernous fistula, three patients for arteriovenous malformations, three patients for dural arteriovenous fistulas, two patients for intracranial aneurysms and one patient for vasospasm following subarachnoid hemorrhage. There was no evidence of vasospasm or complications related to the distal position of the guide catheter.ConclusionUtilization of the guide catheter in extremely distal positions is safe and effective, allowing for treatment of traditionally inaccessible lesions. The guide catheter allows for more distal placement and greater proximal support to access neurovascular lesions in the setting of tortuous cervical and/or intracranial vasculature.
E-023 Progressive occlusion in aneurysms treated with stent assisted coiling: flow diversion?
Authors: Izar B , Rai A , Carpenter J , Raghuram K 
Published: December 2010

BackgroundTreatment of intracranial aneurysms using stent assisted coiling (SAC) has broadened the range of endovascular therapies for these aneurysms.ObjectiveOur goal was to assess the long term durability of SAC with specific attention to progressive aneurysm occlusion anecdotally observed in these patients.Materials and methodsA total of 84 aneurysms in 80 patients were initially assessed. Of these, 59 patients on whom long term follow-up was available were included. Immediate post-treatment and follow-up angiograms were evaluated by two independent observers and graded for aneurysm coil coverage (>95%; 85–95%, <85% of the aneurysm volume containing any loop of coil) and intra-aneurysmal flow (no flow, neck remnant, flow beyond the neck). Aneurysm morphology (spherical vs ellipsoid), orientation (sidewall vs bifurcation) and volume were also recorded, as was the packing density of the coil mass. Progressive occlusion was defined as decreased intra-aneurysmal flow or increased coil coverage on the follow-up angiogram.ResultsThe mean follow-up duration was 20.6 months (range 1.2–57.2 months). The mean aneurysm size was 8.4 mm (maximum dimension) and the mean packing density was 32.6%. On the initial treatment, >95% coil coverage was achieved in 81% of patients. On the immediate post-treatment angiogram, 71.1% of the patients had either no intra-aneurysmal flow or flow at the neck while 28.9% demonstrated flow beyond the neck. On the follow-up study, however, 91.5% of the patients had no flow or flow limited to the neck while the percentage of patients with flow beyond the neck was reduced to only 8.4%. Thus 35.6% (21/59) of patients demonstrated progressive reduction in the intra-aneurysmal flow on follow-up imaging. The most important predictor for progressive aneurysm occlusion was the aneurysm orientation; side wall aneurysms demonstrating a higher propensity for progressive occlusion than bifurcation aneurysms (p=0.02). This was independent from aneurysm volume, packing density and initial coil coverage. After orientation, aneurysm shape was the strongest predictor, with a spherical shape showing greater progressive occlusion than a complex or ellipsoid shape (p=0.05).ConclusionSidewall aneurysms with a relatively homogeneous shape have the greatest propensity of showing progressive aneurysm occlusion when treated with SAC. This could possibly be secondary to a higher degree of flow diversion seen in the side wall as opposed to bifurcation aneurysms. This is also important because in these aneurysms leaving a neck remnant or small amount of intra-aneurysmal flow as opposed to taking the added risk of complete occlusion by additional coils may be a safe choice.
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

BackgroundIntra-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.MethodsWe 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.ResultsDespite 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).ConclusionsMeta-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.