bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

IntroductionDural 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.MethodsThree 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.ResultsAll 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.ConclusionSuccessful 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

BackgroundThere 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.MethodsAt 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.ResultsThe 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%.ConclusionThe 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

PurposeThe 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.ResultsBased 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.ConclusionDose 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

IntroductionCarotid 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 methodsDuring 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).ResultsThe 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.ConclusionsEmergent 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

ObjectiveThe authors describe the experience of robotic digital subtraction angiography (DSA) system in the hybrid operation room (OR)MethodsA 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.Results501 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.ConclusionThe 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 purposeCerebral 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 methodsRetrospective review of SAH patients admitted from July 2003 to January 2008.ResultsOf 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.ConclusionEndovascular 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

ObjectAlthough 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.MethodsA 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.ConclusionEndovascular 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

IntroductionCarotid 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 methodsFollowing 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.ResultsSuccessful 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).ConclusionCarotid 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

IntroductionThe 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.MethodA meta-analysis of individual patient data was conducted.ResultsPooled 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).ConclusionWe 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
E-007 Y-Stenting for the treatment of basilar apex aneurysms
Authors: Albuquerque F , McDougall C 
Published: December 2010

IntroductionDespite advances in surgical and endovascular treatment of intracranial aneurysms, the management of wide necked basilar tip aneurysms poses substantial treatment challenges. Y stenting, in which one stent is deployed through the side wall tines of a previously placed stent, is a feasible adjunct to coiling of these aneurysms. Case series describing this technique are small with limited follow-up. We describe our experience with the Y stent assisted, coil embolization of basilar tip aneurysms in the largest case series to date with medium term follow-up data.MethodsA review of our prospectively maintained database from 2004 to 2009 was performed to assess technical factors associated with treatment, complications and radiographic follow-up of patients undergoing Y stenting for basilar apex aneurysms.Results11 patients with wide necked basilar tip aneurysms were treated. Average follow-up was 13 months. Post-procedure surveillance was carried out by MR angiography (n=6), cerebral angiogram (n=9) or CT angiography (n=1), with several patients undergoing multiple types of radiographic follow-up. All patients’ aneurysms were completely or nearly completely (>95%) occluded at the time of treatment. No patient required retreatment. One patient suffered an asymptomatic vertebral artery dissection that required stenting and another suffered a minor stroke but recovered completely.ConclusionY stenting is a viable treatment modality for this complex subgroup of aneurysms. Our series demonstrated the safety of this technique, with no patients suffering permanent complications. While the efficacy of Y stenting has yet to be established, medium term radiographic follow-up suggests durable results.