Autoimmune, neurological, and venous thromboembolic adverse events after immunisation of adolescent girls with quadrivalent human papillomavirus vaccine in Denmark and Sweden: cohort study
Authors: L. Arnheim-Dahlstrom, B. Pasternak, H. Svanstrom, P. Sparen, A. Hviid
Journal: BMJ (2013)

<h3>Objective</h3> The use of cone beam imaging during neurointerventional procedure has been increasing rapidly. Initially used as a CT-scan for evaluation of intra-procedural complications such as hemorrhage, it has evolved to provide details of implanted devices such as flow diverters. The aim of this study is to present our experience using cone beam CTA with intra-arterial injection and provide a step-by-step approach for post-processing in a practical protocol for daily use. <h3>Methods</h3> After institutional IRB approval was obtained, the neurointerventional database of our institution was retrospectively reviewed from July of 2012 to March of 2015. All patients who underwent cone beam intra-arterial CTA for evaluations of implanted flow diverting devices were reviewed. The patient age and gender, aneurysm location (ICA-cavernous, ICA-paraclinoid and ICA-distal; MCA, ACA-acom, ACA-pericallosal, VA), type (saccular, dissecting fusiform or blister) and size, device used, injection technique (contrast dilution, rate and volume) and reconstruction protocol was included in the analysis. <h3>Results</h3> Among the patients in our neurointerventional database, 50 (39 women and 11 men) out of 80 patients met the inclusion criteria in our study. All procedures were performed under general anesthesia using biplane angiographic equipment (Philips Allure FD20/10). Patients’ ages ranged from 25 to 80 years old. The aneurysms treated were located in the ICA-cavernous in 6 cases, ICA-paraclinoid in 25 cases, ICA-distal in 9 cases, MCA in 4 cases, ACA-acom in 2 cases, ACA-pericallosal in 1 case and VA in 3 cases; 43 were saccular, 5 fusiform and 2 ruptured blister aneurysms. Overall, there were 31 small, 15 large, and 4 giant aneurysms. Pipeline (Covidien/Medtronic) was the predominant device used in 47 procedures. Two injection techniques were used: 2.5 mL/s for a total volume of 55 mL with a 2 s imaging delay or 3 mL/s for a total volume of 70 mL with a 3 s imaging delay; contrast (Ioxilan 300 mgI/mL) dilution was 10 to 20% in all cases. All acquired images were post-processed using our standardized protocol through the Philips Xtravision workstation. The devices landing zones, conformability to the arterial geometry, presence of deformities, and wall apposition were successfully and adequately visualized in all cases. In aneurysms that had been coiled as well (9 cases), the use of metal artifact reduction program was felt to enable satisfactorily the evaluation of the implanted devices. <h3>Conclusions</h3> The use of cone beam intra-arterial CTA after use of flow diverters is an extremely useful tool providing important information about the implanted device which may translate into better outcomes. <h3>Disclosures</h3> G. Dabus: 2; C; Covidien/Medtronic, Microvention/Terumo. 4; C; InNeuroCo, Medina Medical, Surpass/Stryker. I. Linfante: 2; C; Covidien/Medtronic. 4; C; InNeuroCo, Surpass/Stryker.