D Tubman

Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline Embolization Device

Background There is wide variability in the reported incidence of perioperative thromboembolic (0–14%) and hemorrhagic (0–11%) complications after Pipeline Embolization Device (PED) procedures for cerebral aneurysm treatment, which could be partly due to differences in patient response to the P2Y12 receptor antagonist administered while the PED endothelializes. This study aims to identify an optimal pre-procedure P2Y12 reaction units (PRU) value range and determine the independent predictors of perioperative thromboembolic and hemorrhagic complications after PED procedures. Methods We recorded patient and aneurysm characteristics, P2Y12 receptor antagonist administered, pre-procedure PRU value with VerifyNow, procedural variables and perioperative thromboembolic and hemorrhagic complications up to postoperative day 30 after PED procedures at our institution during an 8-month period. Perioperative complications were considered major if they caused a permanent disabling neurological deficit or death. Multivariate regression analysis was performed to identify independent predictors of perioperative complications in our cohort. Results Forty-four patients underwent 48 PED procedures at our institution during the study period. There were eight thromboembolic and hemorrhagic perioperative complications in our cohort (16.7%), four of which were major (8.3%). A pre-procedure PRU value of <60 or >240 (p=0.02) and a technically difficult procedure (p=0.04) were independent predictors of all perioperative complications. A pre-procedure PRU value of <60 or >240 (p=0.004) and a history of hypertension (p=0.03) were independent predictors of major perioperative complications. Conclusions In our cohort, a pre-procedure PRU value of <60 or >240 was the strongest independent predictor of all and major perioperative thromboembolic and hemorrhagic complications after PED procedures.

Last-Recorded P2Y12 Reaction Units Value Is Strongly Associated with Thromboembolic and Hemorrhagic Complications Occurring Up to 6 Months after Treatment in Patients with Cerebral Aneurysms Treated with the Pipeline Embolization Device

BACKGROUND AND PURPOSE: A recent study identified a preprocedural P2Y12 reaction units value of <60 or >240 as a strong independent predictor of perioperative thromboembolic and hemorrhagic complications after treatment of cerebral aneurysms with the Pipeline Embolization Device. This study aimed to determine whether a last-recorded P2Y12 reaction units value of <60 or >240 predicts thromboembolic and hemorrhagic complications up to 6 months after treatment of cerebral aneurysms with the Pipeline Embolization Device in the same patient cohort. MATERIALS AND METHODS: We recorded patient and aneurysm characteristics, P2Y12 receptor antagonist administered, P2Y12 reaction units value with VerifyNow, procedural variables, and thromboembolic and hemorrhagic complications up to 6 months after Pipeline Embolization Device procedures at our institution during an 8-month period. Complications causing a permanent disabling neurologic deficit or death were considered major. Multivariate regression analysis was performed to identify independent predictors of thromboembolic and hemorrhagic complications. RESULTS: Forty-four patients underwent 48 Pipeline Embolization Device procedures at our institution during the study period. There were 11 thromboembolic and hemorrhagic complications up to 6 months after treatment in our cohort (22.9%), 5 of which were major (10.4%). A last-recorded P2Y12 reaction units value of <60 or >240 was the only independent predictor of all (P = .002) and major (P = .03) thromboembolic and hemorrhagic complications in our cohort. Most patients (71%) required, on average, 2 adjustments to the dose or type of P2Y12 receptor antagonist to remain within the 60–240 target P2Y12 reaction units range. CONCLUSIONS: In our cohort, a last-recorded P2Y12 reaction units value of <60 or >240 was the only independent predictor of all and major thromboembolic and hemorrhagic complications up to 6 months after Pipeline Embolization Device procedures.

Variability in initial response to standard clopidogrel therapy, delayed conversion to clopidogrel hyper-response, and associated thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms

Background and purpose Variability in response to clopidogrel therapy is increasingly being recognized as an important factor in thromboembolic and hemorrhagic complications encountered after neurointerventional procedures. This study aims to determine the variability in response to clopidogrel therapy and associated complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms. Methods We recorded baseline patient characteristics, co-administered medications, P2Y12 reaction units (PRU) values with VerifyNow, clopidogrel dosing, and thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms at our institution during a 19 month period. Results 100 patients were included in the study, 76 women and 24 men, mean age 57.3u2005years. 15 patients exhibited an initial clopidogrel hypo-response (PRU >240) and 21 patients an initial clopidogrel hyper-response (PRU <60). 36 patients had a follow-up VerifyNow test performed without changes to the standard 75u2005mg daily clopidogrel dose, which demonstrated that 59% of patients who had initially been within the target 60–240 PRU range exhibited a delayed conversion to clopidogrel hyper-response. In our cohort, a clopidogrel hypo-response was associated with a significantly increased risk of thromboembolic complications in patients undergoing cerebral aneurysm treatment with stent assistance or the pipeline embolization device (60%, p=0.003), while a clopidogrel hyper-response was associated with a significantly increased risk of major hemorrhagic complications in all patients undergoing endovascular treatment of cerebral aneurysms (11%, p=0.016). Conclusions We found wide and dynamic variability in response to clopidogrel therapy in patients undergoing endovascular treatment of unruptured cerebral aneurysms, which was significantly associated with thromboembolic and major hemorrhagic complications in our cohort.

Diagnostic Yield of Catheter Angiography in Patients with Subarachnoid Hemorrhage and Negative Initial Noninvasive Neurovascular Examinations

These authors explored the diagnostic yield of DSA in patients with SAH and previously negative CTA or MRA. A total of 55 patients who presented with diffuse SAH, perimesencephalic SAH, or sulcal SAH received CTA (n= 47) or MRA (n= 8). Despite normal findings on CTA or MRA, DSA showed vascular lesions in 11% of patients with diffuse SAH and in 1 patient with sulcal SAH. The investigators concluded that DSA is a valuable tool in patients with diffuse or sulcal SAH in whom previous noninvasive examinations are negative. BACKGROUND AND PURPOSE: The yield of DSA in patients with SAH and negative initial noninvasive neurovascular examinations (CTA or MRA) is not well-understood. This study aimed to determine the yield of DSA for the detection of causative vascular lesions in this clinical scenario. MATERIALS AND METHODS: We examined the yield of DSA for the detection of causative vascular lesions in a cohort of patients presenting to our institution with SAH and negative initial noninvasive neurovascular examinations during a 5-year period. Two experienced neuroradiologists independently evaluated the NCCT to determine the SAH pattern (diffuse, perimesencephalic, or peripheral sulcal) and the catheter angiograms to assess the presence of a causative vascular lesion. RESULTS: Fifty-five patients were included in the study, with a mean age of 58.2 years (median, 58 years; range, 25–88 years). Twenty-eight patients were men (50.9%), and 27 were women (49.1%). The initial noninvasive examination was a CTA in 47 patients (85.5%) and an MRA in 8 patients (14.5%). Thirty-three patients had diffuse SAH (60%); 11, perimesencephalic SAH (20%); and 11, peripheral sulcal SAH (20%). DSA demonstrated a causative vascular lesion in 6 patients (10.9%), 5 of whom had diffuse SAH (yield of 15.2%) and 1 of whom had peripheral sulcal SAH (yield of 9.1%). No causative vascular lesions were found in patients with perimesencephalic SAH. CONCLUSIONS: DSA is a valuable tool in the evaluation of patients with diffuse and peripheral sulcal SAH who have negative initial noninvasive neurovascular examinations, demonstrating a causative vascular lesion in 15.2% and 9.1% of patients, respectively.

Hydrosyringomyelia and diastematomyelia detected by MRI in myelomeningocele

Magnetic resonance imaging of the spine in 45 patients with myelomeningocele revealed hydrosyringomyelia in 24 and diastematomyelia in two. No patient at initial imaging manifested symptoms referable to hydrosyringomyelia; both patients with diastematomyelia had flaccid lower extremities. One patient developed an upper extremity monoparesis which resolved with syringo-peritoneal shunt placement; no other patient manifested symptoms or required surgery. Ventriculoperitoneal shunt malfunction produced reversible distention of the syrinx in another patient who remained asymptomatic.

Diagnostic yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage, negative initial CT and catheter angiograms, and a negative 7 day repeat catheter angiogram

Purpose The yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage (SAH), negative initial CT and catheter angiograms (CT angiography (CTA), DSA), and negative 7 day repeat DSA is not well understood. Our aim was to determine the yield of delayed neurovascular imaging for the detection of causative vascular lesions in this clinical scenario. Methods We retrospectively examined the yield of delayed CTA and DSA for the detection of causative vascular lesions in patients presenting to our institution with SAH, negative initial CTA and DSA examinations, and a negative 7 day repeat DSA during a 6.5 year period. Two neuroradiologists evaluated the non-contrast CTs to determine the SAH pattern, and the delayed CTAs and DSAs to assess for the presence of a causative vascular lesion. Results 39 patients were included: 23 men (59%) and 16 women (41%), mean age 55.5u2005years (range 33–75). 25 patients had diffuse SAH (64.1%), 12 had perimesencephalic SAH (30.8%), and two had peripheral sulcal SAH (5.1%). The delayed neurovascular examination was CTA in 30 patients (76.9%) and DSA in nine patients (23.1%). Mean time to delayed CTA or DSA was 34.9u2005days (median 34, range 14–69u2005days). Delayed CTA demonstrated a causative vascular lesion in two patients (5.1%, one small internal carotid artery aneurysm and one small pontine arteriovenous malformation), both with diffuse SAH (yield 8%). Conclusions Delayed neurovascular imaging is valuable in the evaluation of patients with diffuse SAH who have negative initial CTA and DSA examinations and a negative 7 day repeat DSA, demonstrating a causative vascular lesion in 8% of patients.

Concurrent Basilar Artery Double Fenestration With Aneurysm and Vertebral Artery Dissection: Case Report and Literature Review of Rare Cerebrovascular Abnormalities

Many disorders can cause aneurysm and/or dissection of the cerebral arteries, including fibromuscular dysplasia (FMD), connective tissue disorders, cerebral vasculitis, infection, and vascular malformations. Arterial fenestration is a rare congenital finding that can also cause aneurysms, and can rarely dissect and bleed. Treatment of aneurysm and dissection with subarachnoid hemorrhage can be very complicated, and requires case-by-case analysis of the risks and benefits of antithrombotic therapy. To the authors knowledge, no case of double fenestration of the basilar artery has been reported. This report presents a case of concurring vertebral artery dissection and double fenestration of the basilar artery with aneurysm. The fenestration and FMD are considered possible main contributing causes of this presentation. A literature review of cerebrovascular fenestration and FMD is provided and the relationship between the 2 is considered. Lastly, the use of antithrombotic therapy in the setting of subarachnoid hemorrhage, dissection, and stent placement is discussed.

Complicated cerebral venous sinus thrombosis with intracranial hemorrhage and mastoiditis.

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke, occurring when a blood clot forms in any of the brain venous sinuses. Symptoms include neurological deficits, headache, seizures, and coma. There are many predisposing factors for CVST including prothrombotic conditions, oral contraceptives, pregnancy/puerperium, malignancy, infection, and head injury. Cerebral venous sinus thrombosis has no identifiable underlying etiology in about 12.5% to 33% of the cases. Diagnosis has become easier with newer imaging techniques, such as magnetic resonance venography. The treatment options for CVST include symptomatic treatment, anticoagulation (AC), thrombolysis, and thrombectomy. Controversy exists over the efficacy and safety of AC in patients with CVST with concurrent intracranial hemorrhage (ICH). We present a complex case of CVST with ICH and mastoiditis as well as provide a literature review about CVST.

Magnetic resonance imaging in a patient with I-cell disease

Autopsy reports in I-cell disease patients describe no salient abnormality of central nervous system morphology. Magnetic resonance imaging of the cranium in a patient with I-cell disease showed ventriculomegaly with frontal lobe atrophy and bifrontal leukomalacia. Central nervous system morphological abnormalities may occur in a subset of patients with I-cell disease.

E-065 Medium-Term Clinical Outcome of Patients with Aneurysmal Subarachnoid Haemorrhage Treated Endovascularly within the Framework of a Multi-Disciplinary Neurovascular Team at a Tertiary Referral Medical Centre over a 45-Month Period

Purpose To determine the medium-term clinical outcome in a cohort of patients presenting with aneurysmal subarachnoid haemorrhage (SAH) treated endovascularly within the framework of a multi-disciplinary neurovascular team at a tertiary referral medical centre over a 45-month period. Methods We conducted a retrospective review of all patients who presented to our institution with aneurysmal SAH and underwent endovascular treatment of the ruptured aneurysm within the framework of a multi-disciplinary neurovascular team from January 1st, 2009, until September 30th, 2012. Baseline clinical characteristics, surgical and endovascular interventions performed and discharge disposition were recorded. Clinical outcome at the time of last follow-up was assessed with the modified Rankin Scale (mRS). A good clinical outcome was defined as an mRS 0–2. Results One-hundred and twenty-four patients presented with aneurysmal SAH and underwent endovascular treatment of the ruptured aneurysm at our institution during the study period. Eighty-seven patients were female (70.2%) and 37 male (29.8%), with a mean age of 56.2 years (median 57 years, range 22–91 years). Sixty-eight patients required placement of an external ventricular drain (54.8%), 28 placement of a ventriculoperitoneal shunt (22.6%), and 6 a decompressive craniectomy (4.8%). Twenty-six patients required endovascular treatment of symptomatic cerebral vasospasm (21%), 85% of which were treated with balloon-angioplasty of the affected vessel (s) with or without an intra-arterial nicardipine infusion, and 15% were treated with an intra-arterial nicardipine infusion only. Mean Neuro-ICU length of stay was 14.3 days (median 14.5 days, range 1–39 days). Mean hospital length of stay was 19 days (median 18 days, range 1–39 days). Discharge disposition was home in 62 patients (50%), a rehabilitation facility in 39 patients (31.5%), a skilled nursing facility in 12 patients (9.7%), and 11 patients did not survive the hospitalisation (8.9%). Eight patients were lost to follow-up (6.5%). Mean time to last clinical follow-up for the 105 survivors with follow-up was 14.6 months (median 9.6 months, range 3.7–48 months). Overall, a good clinical outcome at the time of last clinical follow-up was observed in 83 patients (71.6%). The table summarises the clinical outcome at the time of last clinical follow-up according to admission Hunt-Hess scale in our patient cohort. Conclusion The majority (72%) of patients presenting with aneurysmal SAH who underwent endovascular treatment of the ruptured aneurysm within the framework of a multi-disciplinary neurovascular team at our institution demonstrated a good clinical outcome at the time of last clinical follow-up, including 41% of patients with an admission Hunt-Hess scale 4–5. Clinical Outcome at the Time of Last Clinical Follow-up in Patients with Aneurysmal SAH Abstract E-065 Table 1 All patients: Admission Hunt-Hess 1-2: Admission Hunt-Hess 3: Admission Hunt-Hess 4-5: p-value: All patients: 116 (100%) 50 (43.1%) 32 (27.6%) 34 (29.3%) mRS 0-2: 83 (71.6%) 47 (94%) 22 (68.8%) 14 (41.2%) mRS 3: 13 (11.2%) 1 (2%) 4 (12.5%) 8 (23.5%) mRS 4-5: 7 (6%) 0 2 (6.3%) 5 (14.7%) mRS 6: 13 (11.2%) 2 (4%) 4 (12.5%) 7 (20.6%) <0.0001 Disclosures J. Delgado Almandoz: 2; C; Covidien/ev3. Y. Kadkhodayan: None. B. Crandall: 2; C; Covidien/ev3. J. Scholz: None. R. Anderson: None. K. Lockhart: None. T. Mowbray-Donahue: None. K. Uittenbogaard: None. G. Dyste: None. J. Fease: None. D. Tubman: 2; C; Covidien/ev3, MicroVention.