Dion Graybeal

Percutaneous transluminal angioplasty and stenting of midbasilar stenoses: three technical case reports and literature review.

OBJECTIVE AND IMPORTANCE Symptomatic basilar artery stenosis is a highly morbid disease process. Recent technological and pharmaceutical advances make endovascular treatment of this disease process possible. CLINICAL PRESENTATION We report three cases of patients with a symptomatic basilar artery stenosis despite anticoagulation. INTERVENTION All patients were successfully treated with a flexible coronary stent and perioperative antiplatelet medications without incident. Poststenting angiography demonstrated a normal-caliber artery with patent perforators. In one case, a poststenting cerebral blood flow study revealed improved perfusion. CONCLUSION A new generation of stents and balloons makes access to intracranial intradural arterial pathological abnormalities possible. Such devices may well revolutionize the management of ischemic and hemorrhagic intracranial cerebrovascular disease.

Transcranial doppler: An introduction for primary care physicians

Transcranial Doppler (TCD) is a diagnostic tool that can be used at bedside to assess the cerebral vasculature noninvasively. It is inexpensive, safe, and reliable when compared with other techniques. It can be repeated multiple times and can be used for continuous monitoring if needed. Screening of children with sickle cell disease to assess and prevent ischemic strokes and monitoring for vasospasm after subarachnoid hemorrhage are well established, evidenced based utilizations of TCD. It is useful for the evaluation of occlusive intracranial vascular lesions with many emerging indications in the management of ischemic stroke. TCD with micro-bubble enhancement has comparable sensitivity to transesophageal echocardiogram in detecting right-to-left atrial cardiac shunts. TCD is underused as a clinical tool despite well established indications. The pressure to contain increasing medical cost will likely result in increased utilization of this test in future.

Extent of Intra-Arterial Calcification on Head CT Is Predictive of the Degree of Intracranial Atherosclerosis on Digital Subtraction Angiography

Background: Intracranial intra-arterial calcifications (ICAC) are a common finding on head CT examinations, but their significance is not known. The aim of this study is to determine if a relationship exists between ICAC on head CT and the presence of a high-grade atherosclerotic stenosis on cerebral angiography. Methods: This was a retrospective study of 108 consecutive patients admitted to the stroke service at Parkland Hospital in Dallas, Tex., USA. Each patient had undergone a head CT and catheter-based angiographic study to meet the inclusion criteria. Demographic information was recorded along with CT imaging data in regards to the amount of calcification. Angiographic images were reviewed independently, and a comparison was made to determine if calcification was predictive of finding a high-grade stenosis on angiography. Results: A total of 108 consecutive patients with a mean age of 56 ± 12 years were studied. Of the 540 vessels studied, 65 (12%) were found to have a stenosis of ≥50% on angiography, and 71 (13.1%) were found to have a calcium grade of 3 or 4 on head CT. ICAC appeared to be more common in the anterior circulation compared to the posterior circulation. Patients with grade 3 or 4 calcification of an intracranial vessel on head CT were more likely to have a stenosis of ≥50% on cerebral angiography. Conclusions: The presence of ICAC on head CT appears to correlate with the presence of an underlying intracranial stenosis on angiography. Further study is required to validate these preliminary findings.

An echocardiographic-confirmed case of atrial myxoma causing cerebral embolic ischemic stroke: a case report

A myxoma is the most common primary tumor of the heart. It has been reported as the source of a cardiogenic embolism. Therefore, it is important for clinicians to detect the myxoma early via echocardiography to prevent complications, such as syncope, sudden death, and cerebral embolic ischemic stroke. This report presents the case of a 54-year-old female whose clinical manifestation of atrial myxoma was an ischemic stroke. Atrial myxoma was later confirmed as the cause of her symptoms via transesophageal echocardiography.

E-044 Stent Retriever Thrombectomy and Local Aspiration with a Navigable and Flexible Second Generation Support Catheter for Acute Ischemic Stroke: The "Sol-Arc" Technique

Multiple recent randomized controlled trials have proven the benefit of mechanical thrombectomy using stent retrievers for emergent large vessel occlusion (ELVO).1–5 Techniques currently used for endovascular treatment of stroke employ either direct aspiration, stent retriever thrombectomy or a combination of both. When stent retrievers are used, temporary flow arrest with an extracranial balloon guide catheter or assisted local aspiration with a large bore intracranial suction catheter is recommended. This allows for more complete recanalization and prevents embolization to previously uninvolved territories. Recent advancements in large bore intracranial suction catheter technology have made it easier to utilize coaxial stent retriever thrombectomy assisted by local aspiration. At our high-volume comprehensive stroke center, we have found the second generation large bore intracranial Arc support catheter (ev3 Neurovascular, Irvine, CA) to be extremely effective when used in combination with the Solitaire stent retriever (ev3 Neurovascular, Irvine, CA). We have found the Arc support catheter to be much more navigable, less prone to kinking and easier to deliver into the M1 segment (without causing spasm) than the first generation local aspiration catheters. Additionally, the Arc support catheter is less costly than the currently available suction catheters. The Sol-Arc technique begins with placement of a stent retriever device across the embolic occlusion by deployment though a 021 or 027 microcatheter. This microcatheter is placed coaxially through the Arc support catheter which is positioned just proximal to the embolus. After waiting 5 minutes, the stent retriever is pulled inside the Arc support catheter which is simultaneously aspirated. Subsequently, the Arc support catheter is removed while aspirating the guiding sheath in the neck. This technique should allow for faster, safer and more successful stent retriever thrombectomy when used in conjunction with local aspiration. Disclosures A. Onofrio: None. A. Miller: None. J. Hise: None. I. Thacker: None. J. Haithcock: None. D. Graybeal: None. K. Layton: None.

Successful reperfusion of bilateral middle cerebral artery embolic occlusions using stent retriever thrombectomy

ABSTRACT A 40-year-old woman presented to our stroke center for a left middle cerebral artery embolic occlusion. This was successfully treated with mechanical thrombectomy using a stent retriever and balloon guide catheter aspiration. The patient was discharged home in good condition on clopidogrel but returned 2 months later with a contralateral right middle cerebral artery embolic occlusion. This was also successfully treated, this time with a stent retriever and local aspiration (Sol-Arc technique). She was once again discharged in good condition but with warfarin and an implanted loop recorder. This case demonstrates the feasibility of short-term bilateral mechanical thrombectomy for embolic middle cerebral artery occlusions.

DWI Abnormalities and Clinical Characteristics in TIA Patients

The authors conducted a study to determine if diffusion-weighted imaging (DWI) is more sensitive and specific in evaluating lesions from transient ischemic attacks (TIA) than conventional computed tomography or magnetic resonance imaging (MRI). MRI including DWI was performed in 129 consecutive patients with TIA with 14 days after the episode. The frequency TIA-related DWI abnormalities was noted and compared with the clinical background of patients with and without DWI abnormalities. The TIA patients that had DWI abnormalities correlated with prolonged TIA duration and disturbance of higher brain function, Ischemia that is sustained and extensive may contribute to DWI abnormalities in TIA patients.