Athos Patsalides

Long-term clinical and angiographic results of Neuroform stent-assisted coil embolization in wide-necked intracranial aneurysms.

BACKGROUNDnNeuroform stent-assisted coil embolization facilitates the endovascular treatment of wide-necked intracranial aneurysms. However, the safety and efficacy of its long-term use have not been fully elucidated.nnnOBJECTIVEnTo retrospectively examine the long-term results of Neuroform stent usage in conjunction with coil embolization in wide-necked intracranial aneurysms.nnnMETHODSnBetween November 2002 and December 2010, 79 patients harboring wide-necked intracranial aneurysms were treated with use of the Neuroform stent. The stenting procedure failed in 2 patients. Therefore, 77 patients harboring 79 intracranial aneurysms were included for analysis. Patient and aneurysm characteristics, progression of aneurysm occlusion, and occurrence of complications were analyzed. Follow-up imaging included digital subtraction angiography (DSA) or magnetic resonance angiography (MRA). Kaplan-Meier analysis, as well as univariate analysis were performed to determine the progression of aneurysm occlusion and to examine the predictive factors for complete aneurysm occlusion, respectively.nnnRESULTSnOverall, complete aneurysm occlusion was observed in 42.4% of the cases immediately after treatment and progressed to 96.5% at 7-year follow-up. The mean angiographic follow-up time was 25.8 months (range, 0-84 months). Eleven aneurysms (14%) were re-treated. Sixty-eight patients (88.3%) had favorable clinical outcome with a modified Rankin Scale (mRS) ≤ 1, 3 patients (3.9%) had an mRS of 2, and 5 patients (6.5%) did not have a clinical follow-up. The mean clinical follow-up time was 45.4 months (range, 3-92 months). One patient (1.3%) died of a procedure-related hemorrhage.nnnCONCLUSIONnNeuroform stent-assisted coil embolization of wide-necked intracranial aneurysms prevents hemorrhage and provides a high rate of aneurysm occlusion at long-term follow-up.

Vascular anatomy of the spinal cord

In this article, a detailed description of the normal arterial supply and venous drainage of the spinal cord is provided, and the role of catheter angiography and MR angiography in depicting the vascular anatomy of the spinal cord is discussed.

Endovascular Treatment of Spinal Arteriovenous Lesions: Beyond the Dural Fistula

SUMMARY: During the past few decades, there have been significant advances in the understanding of spinal vascular lesions, mainly because of the evolution of imaging technology and selective spinal angiography techniques. In this article, we discuss the classification, pathophysiology, and clinical manifestations of spinal vascular lesions other than DAVFs and provide a review of the endovascular approach to treat these lesions.

Intraprocedural Aneurysmal Rupture during Coil Embolization of Brain Aneurysms: Role of Balloon-Assisted Coiling

BACKGROUND AND PURPOSE: Intraprocedural aneurysmal rupture is a feared complication of coil embolization of intracranial aneurysms and is associated with high rates of morbidity and mortality. We report the incidence, endovascular management, and clinical outcome of patients with IAR, with emphasis on the role of the balloon-assisted technique. MATERIALS AND METHODS: We conducted a retrospective analysis of all intracranial aneurysms treated by coil embolization between September 2001 and June 2011. All patients with IAR were studied. Comparison of immediate clinical outcomes was performed by using univariate analysis (Fisher exact test). RESULTS: Of 652 intracranial aneurysms treated with coil embolization, an IAR occurred in 22 (3.4%). Rupture occurred during placement of coils in 18 cases, microcatheters in 2 cases, and a guidewire in 1 case, and during induction of anesthesia in 1 case. Before treatment, 15 of 22 (68%) patients were in good clinical condition (WFNS grade I). There were fewer patients with worsening of the WFNS grade following an IAR when the balloon-assisted technique was used (7.7%) compared with when it was not (55.5%) (P = .023). Death occurred in 2 (9.1%) patients. CONCLUSIONS: IAR is a potentially serious complication of coil embolization. If IAR occurs, balloon-assistance is helpful in obtaining rapid hemostasis resulting in better short-term outcomes.

External Validation of the Cincinnati Prehospital Stroke Severity Scale

BACKGROUNDnThe Cincinnati Prehospital Stroke Severity Scale (CPSSS) was recently developed to predict large-vessel occlusions (LVOs) in patients with acute ischemic stroke (AIS). In its derivation study, which consisted of patients enrolled in thrombolysis and endovascular therapy trials, the CPSSS had excellent discriminatory performance. We sought to externally validate the CPSSS in an independent cohort.nnnMETHODSnUsing our institutions prospective stroke registry, we calculated CPSSS scores for all patients diagnosed with AIS at Weill Cornell Medical Center in 2013 and 2014. The primary outcome was presence of LVO and the secondary outcome was a National Institutes of Health Stroke Scale (NIHSS) score of 15 or higher. Harrells c-statistic was calculated to determine the CPSSS scores discriminatory performance. Using the previously defined cut-point of 2 or higher (range 0-4), we evaluated the test properties of the CPSSS for predicting study outcomes.nnnRESULTSnAmong 751 patients with AIS, 664 had vessel imaging and were included in the final analysis. Of these patients, 80 (14.2%) had LVOs and 117 (17.6%) had an NIHSS score of 15 or higher. The median CPSSS score was 0 (interquartile range 0-1) and 133 patients (20%) had scores of 2 or higher. c-statistic was .85 (95% confidence interval [CI] .81-.90) for predicting LVO and .94 (95% CI .92-.97) for predicting an NIHSS score of 15 or higher. Using a cut-point of 2 or higher, the CPSSS was 70.0% sensitive and 86.8% specific for predicting LVO, and 87.2% sensitive and 94.3% specific for predicting an NIHSS score of 15 or higher.nnnCONCLUSIONSnIn a cohort of patients with AIS treated at a tertiary-care stroke center, the CPSSS had reasonable sensitivity and specificity for predicting LVO and severe stroke. Future studies should aim to prospectively validate the score in emergency responders.

Principles in Case-Based Aneurysm Treatment: Approaching Complex Lesions Excluded by International Subarachnoid Aneurysm Trial (ISAT) Criteria

OBJECTIVEnTo review notable aneurysm cases that required complex decision making from a single institution and to examine available literature when relevant to highlight evidence-based paradigms for treatment of complex aneurysms.nnnMETHODSnCase illustrations were used to highlight topics in complex aneurysm treatments. Reviews of the literature were conducted to evaluate the evidence for available treatment models.nnnRESULTSnCurrent modalities for treating complex aneurysms involve endovascular and microsurgical tools.nnnCONCLUSIONSnInnovations in both arms of the cerebrovascular field will continue to advance the field and provide novel approaches to these complex lesions.

Mechanism of Acute Ischemic Stroke in Patients with Severe Middle Cerebral Artery Atherosclerotic Disease

BACKGROUNDnIntracranial atherosclerotic disease (ICAD) is one of the most common causes of ischemic stroke worldwide. Although the pathogenesis of cerebral infarct in ICAD has been reported from autopsy series, the mechanism of stroke is not well known. This study used baseline perfusion imaging and diffusion-weighted imaging (DWI) or computerized tomography (CT) imaging to help identify the mechanism of stroke in ICAD involving the middle cerebral artery (MCA).nnnMETHODSnWe retrospectively reviewed baseline CT or magnetic resonance (MR) perfusion studies and diffusion-weighted MR imaging or CT scans in patients with severe symptomatic MCA stenosis. Perfusion scans were classified according to stage of perfusion deficit, and the acute stroke patterns were categorized as borderzone, cortical, or perforating artery infarcts according to DWI or noncontrast CT.nnnRESULTSnFifteen patients were included in this analysis. All 15 patients had some type of borderzone infarct. Six had borderzone infarct only, 4 had borderzone and cortical infarcts, and 5 had borderzone, cortical, and perforating artery infarcts. Thirteen of the 15 patients had baseline perfusion deficits.nnnCONCLUSIONSnIn patients with severe MCA ICAD, the mechanism of stroke is multifactorial, but hemodynamic insufficiency plays a significant role. This finding is important in selecting a subgroup of patients who may benefit from revascularization.

Endovascular Therapy for Acute Stroke in Patients With Cancer

Intravenous thrombolysis is the standard treatment for acute ischemic stroke (AIS). However, patients with cancer who have stroke are often precluded from therapy because of coagulopathy or recent surgery. Endovascular therapy may be a more suitable recanalization strategy for some patients with cancer and stroke, but no prior detailed reports documenting its use in this population exist. We present a case series from a tertiary care referral center of 2 patients with active systemic cancer who were successfully treated with endovascular therapy for AIS. Both patients had active lung cancer with excellent premorbid functional status and presented with severe AIS from left middle cerebral artery occlusions. Intravenous thrombolysis was deferred because of absolute contraindications. Mechanical embolectomy was performed instead and revascularization was achieved within 5 hours in both patients, resulting in dramatic neurological recoveries—National Institutes of Health Stroke Scale improved from 14 to 0 and from 23 to 3 from admission to discharge, respectively. In conclusion, endovascular therapy may be beneficial for select patients with cancer and AIS who are ineligible for intravenous thrombolysis. However, further studies are needed to determine the safety and efficacy of endovascular therapy in the population with cancer.

Therapeutic management of cerebral arteriovenous malformations: a review.

The therapeutic management of cerebral arteriovenous malformations has undergone significant change over the past 40 years. Embolization, radiosurgery, advanced imaging modalities, neuropsychological testing and advances in surgical technique has both significantly improved our ability to treat patients, as well as confounding the landscape as to what constitutes best medical practice. Variability in natural history provides additional challenges in that it is challenging to determine an accurate estimate of the risk of hemorrhage, morbidity and mortality. It is clear that the complexity of the treatment of these lesions demands a multidisciplinary approach. The need for a team of neurosurgeons, interventional and diagnostic neuroradiologists, neurologists, radiation oncologists and neuropsychologists will improve outcomes and aid in determining best therapy for patients.

Angiographic Blush after Mechanical Thrombectomy is Associated with Hemorrhagic Transformation of Ischemic Stroke

BACKGROUND AND PURPOSEnRisk factors for hemorrhagic transformation of ischemic stroke after mechanical thrombectomy (MT) are not well established. We conducted a study to determine if prominent angiographic cerebral vascularity following recanalization with thrombectomy (angiographic blush) is associated with hemorrhagic transformation.nnnMETHODSnUsing the Cornell AcutE Stroke Academic Registry, we identified stroke patients who had thrombectomy and achieved recanalization of anterior circulation large-vessel occlusion between 2012 and 2015. The exposure variable was presence of angiographic blush after recanalization, defined as capillary blush with or without early venous drainage. The primary outcome was volume of hemorrhagic transformation on brain imaging after thrombectomy, as determined by semiautomated volumetric analysis on computed tomography or magnetic resonance imaging among those adjudicated to have hemorrhagic conversion by neuroradiology investigators blinded to angiography results. Using a doubly robust estimator with propensity scores and outcome regression adjusting for demographics and known risk factors for hemorrhagic transformation, we evaluated whether angiographic blush after recanalization is associated with an increased volume of hemorrhagic transformation.nnnRESULTSnAmong 48 eligible patients, 31 (64.6%) had angiographic blush and 26 (54.2%) had radiographic hemorrhagic transformation (mean volume, 7.6 ml). Patients with angiographic blush averaged lower thrombolysis in cerebral infarction scores and more often received intravenous thrombolysis. In adjusted analysis, angiographic blush was associated with an increased volume of hemorrhagic transformation: mean volume, 10.3ml (95% CI, 3.7-16.9 ml) with blush versus 1.8ml (95% Confidence Interval (CII = Confidence Interval), 0.1-3.4 ml) without (Pu202f=u202f.01).nnnCONCLUSIONSnPresence of angiographic blush after MT was independently associated with the volume of hemorrhagic transformation.