Edgar A. Samaniego

Closed-cell stent for coil embolization of intracranial aneurysms: clinical and angiographic results

Because recanalization is observed in 20–40% of endovascularly treated aneurysms, these authors report their experience using a closed-cell stent. They treated 161 wide-neck ruptured or unruptured aneurysms with the device and found a nearly 5% death rate and a 3.5% incidence of neurologic deficits. Of the ones available for follow-up, 10% of patients showed recanalization and 6% required retreatment. In-stent stenosis was seen in only 1 instance. Treatment of ruptured aneurysms and premature termination of antiplatelet medication were associated with increased morbidity and mortality but overall these stents were considered to be safe and effective. BACKGROUND AND PURPOSE: Recanalization is observed in 20–40% of endovascularly treated intracranial aneurysms. To further reduce the recanalization and expand endovascular treatment, we evaluated the safety and efficacy of closed-cell SACE. MATERIALS AND METHODS: Between 2007 and 2010, 147 consecutive patients (110 women; mean age, 54 years) presenting at 2 centers with 161 wide-neck ruptured and unruptured aneurysms were treated by using SACE. Inclusion criteria were wide-neck aneurysms (>4 mm or a dome/neck ratio ≤2). Clinical outcomes were assessed by the mRS score at baseline, discharge, and follow-up. Aneurysm occlusion was assessed on angiograms by using the RS immediately after SACE and at follow-up. RESULTS: Eighteen aneurysms (11%) were treated following rupture. Procedure-related mortality and permanent neurologic deficits occurred in 2 (1.4%) and 5 patients (3.4%), respectively. In total, 7 patients (4.8%) died, including 2 with reruptures. Of the 140 surviving patients, 113 (80.7%) patients with 120 aneurysms were available for follow-up neurologic examination at a mean of 11.8 months. An increase in mRS score from admission to follow-up by 1, 2, or 3 points was seen in 7 (6.9%), 1 (1%), and 2 (2%) patients, respectively. Follow-up angiography was performed in 120 aneurysms at a mean of 11.9 months. Recanalization occurred in 12 aneurysms (10%), requiring retreatment in 7 (5.8%). Moderate in-stent stenosis was seen in 1 (0.8%), which remained asymptomatic. CONCLUSIONS: This series adds to the evidence demonstrating the safety and effectiveness of SACE in the treatment of intracranial aneurysms. However, SACE of ruptured aneurysms and premature termination of antiplatelet treatment are associated with increased morbidity and mortality.

Inpatient and Community Ischemic Strokes in a University Hospital

Background: Previous studies have shown that inpatient strokes are common and severe. We sought to characterize the risk factors, stroke subtypes, timing of acute stroke evaluation and frequency of thrombolytic therapy in inpatient ischemic strokes compared with community ischemic strokes. Design/Methods: The hospital records of patients admitted for acute ischemic stroke between 1996 and 2002 were reviewed. Acute stroke was defined as occurrence of stroke symptoms within 72 h, and in-hospital status was assigned if the patient was currently admitted for another illness at the time of the stroke. Patient demographics such as medical versus surgical service, admission diagnoses, clinical features including stroke risk factors, access to thrombolytic therapy and immediate outcome were analyzed. Results: Of 947 patients with acute ischemic stroke, 161 (17.0%) had strokes occurring while already in the hospital (IHIS), compared to 786 (83%) that occurred in the outpatient community (CIS). Approximately two thirds of IHIS occurred on medical services (102, 63.4%) and one third on surgical services (59, 36.7%). Mean age, male gender, atherothrombotic etiology and risk factors including hypertension, diabetes and smoking history were of similar frequencies in IHIS and CIS, but penetrating artery disease was the cause of only 5.6% of IHIS compared to 21.8% of CIS (p < 0.0001). The mean modified Rankin scale for IHIS at presentation was 4.33 ± 0.74, compared to 3.67 ± 1.03 for CIS (p < 0.0001). Of 161 IHIS patients, 21 (13.0%) had neurological assessment within 3 h of symptom onset, compared to 16.0% of CIS patients (p = 0.403, n.s.), and the rate of thrombolytic therapy was not significant between IHIS (3.7%) and CIS (5.6%) patients. Conclusions: IHIS are common and severer than CIS. The use of thrombolytic therapy in IHIS patients was limited because of time of recognition and inpatient-associated conditions. Increased vigilance for timely neurological assessment of these patients is warranted.

Self-Expandable Stents in the Treatment of Acute Ischemic Stroke Refractory to Current Thrombectomy Devices

Background and Purpose— Vessel recanalization is a strong predictor of good outcome in acute ischemic strokes (AIS) secondary to large vessel occlusions. We report our single-center experience with self-expandable stents in the treatment of AIS. Methods— The stroke database of Baptist Cardiac and Vascular Institute in Miami was retrospectively reviewed from August of 2008 to September of 2010. All cases of AIS in which a self-expandable stents was deployed as acute endovascular intervention were included in the analysis. Criteria for intervention were the onset of neurological symptoms because of AIS, a National Institute of Health Stroke Scale score ≥4 at presentation, stroke attributable to a large vessel occlusion, and failure of arterial thrombolysis or mechanical thrombectomy or both. Good outcome was defined as a modified Rankin Scale score ⩽2 at 1 month from hospital discharge. Results— Nineteen patients with AIS who underwent stenting were identified. Median National Institute of Health Stroke Scale score on admission was 19. Six Enterprise and 13 Wingspan stents were deployed. Recanalization was achieved in 95% occlusions (63% thrombolysis in myocardial infarction grade 3 and 32% thrombolysis in myocardial infarction grade 2). Good clinical outcome was achieved in 42%. No intraprocedural complications occurred and all stents were successfully deployed. Symptomatic intracerebral hemorrhage occurred in 3 (16%) patients, 2 of whom died. Conclusions— Use of self-expandable stents in AIS appears to be safe and may be considered when currently available thrombectomy devices and/or intraarterial thrombolysis fail.

Outcome of Symptomatic Intracranial Atherosclerotic Disease

Background and Purpose— Patients with intracranial atherosclerotic disease have a 3.6% to 22% annual risk of stroke. In this study, we sought to evaluate the natural history and prognosis of patients with symptomatic intracranial atherosclerotic disease who received medical therapy versus percutaneous transluminal angioplasty and stenting (PTAS) at our institution. Methods— Charts of all patients with symptomatic intracranial atherosclerotic disease from July 2004 to September 2007 were reviewed and assessed for history of transient ischemic attack or stroke. Patients were either treated with “best medical therapy” (Medical Therapy Group) or PTAS plus antiplatelet agents (PTAS Group) and followed prospectively. A favorable outcome was defined as the absence of transient ischemic attacks, strokes, or vascular death; modified Rankin Scale of ≤3; and no endovascular reintervention of symptomatic in-stent restenosis. Results— One hundred eleven patients fulfilled entry criteria, with 58 (52.3%) and 53 patients (47.7%) enrolled in the Medical Therapy and PTAS Groups, respectively. Thirty-eight patients of the Medical Therapy Group (65.5%) had a favorable outcome compared with 37 patients of the PTAS Group (69.8%). Combined ischemic end point data for the occurrence of transient ischemic attack, stroke, and vascular death was similar with 14 (24%) events in the Medical Therapy Group versus 15 (28.3%) events in the PTAS Group. Conclusion— Overall, the combined ischemic end point was the same in the Medical Therapy and PTAS Groups.

Crossed Cerebellar Diaschisis in Status Epilepticus

BackgroundCrossed cerebellar diaschisis (CCD) has been reported on positron-emission tomography and single-photon emission computed tomography of stroke patients. Rarely it has been described with brain diffusion-weighted MRI (DWI) of status epilepticus (SE).MethodsCase report.ResultsA 53-year-old woman was found unresponsive after cocaine use. A diagnostic electroencephalogram was consistent with ictal SE. A brain DWI showed reduced diffusion in the left temporo-parietal and occipital cortexes, the left thalamus and the right cerebellum. The DWI changes did not correspond to a vascular territory and were attributed to seizure activity and secondary CCD. A 2-week follow-up DWI showed interval near-complete resolution of the diffusion changes. CCD in SE may represent injury caused by excessive neuronal transmission from prolonged excitatory synaptic activity via the cortico-pontine-cerebellar pathway. Alternatively, it may be a result of interruption of the cortico-pontine-cerebellar pathway with loss of cortical inhibitory input.ConclusionThis case documents CCD during SE, providing further evidence of contralateral cerebellar involvement with a supratentorial epileptiform focus.

Preliminary experience with Precipitating Hydrophobic Injectable Liquid (PHIL) in treating cerebral AVMs

Objective To describe our early experience in treating cerebral arteriovenous malformations (AVMs) with the new Precipitating Hydrophobic Injectable Liquid (PHIL) embolic material. Materials and methods Between June and August 2015 five patients with cerebral AVMs were treated at two tertiary university hospitals. PHIL was used as complementary treatment to Onyx liquid embolic material or as the sole endovascular treatment. Results Five patients (average age 39 years (range 19–73)) with ruptured plexiform AVMs were treated. The group included one patient with Spetzler–Martin grade II AVMs, three grade III, and one grade IV. One grade II and two grade III AVMs were cured. A total of nine pedicles were embolized with an average of two pedicles per session. There were no procedural complications. One patient had a seizure after embolization but a brain CT scan showed no hemorrhage. Conclusions PHIL is a new embolic agent that can be used for the treatment of cerebral AVMs.

Update on pharmacology of antiplatelets, anticoagulants, and thrombolytics

Understanding of the pharmacology of thrombolytics, anticoagulants, and antiplatelets is critical to performing safe and effective endovascular therapy for acute ischemic therapy. This is a basic review of the clinical pharmacologic data on the anticoagulants, antiplatelets, and fibrinolytic agents most commonly used in the treatment of stroke and in the neurointerventional suite.

Stenting in the treatment of acute ischemic stroke: literature review

Recanalization of acute large artery occlusions is a strong predictor of good outcome. The development of thrombectomy devices resulted in a significant improvement in recanalization rates compared to thrombolytics alone. However, clinical trials and registries with these thrombectomy devices in acute ischemic stroke (AIS) have shown recanalization rates in the range of 40–81%. The last decade has seen the development of nickel titanium self-expandable stents (SES). These stents, in contrast to balloon-mounted stents, allow better navigability and deployment in tortuous vessels and therefore are optimal for the cerebral circulation. SES were initially used for stent-assisted coil embolization of intracranial aneurysms and for treatment of intracranial stenosis. However, a few authors have recently reported feasibility of deployment of SES in AIS. The use of these devices yielded higher recanalization rates compared to traditional thrombectomy devices. Encouraged by these results, retrievable SES systems have been recently used in AIS. These devices offer the advantage of resheathing and retrieving of the stent even after full deployment. Some of these stents can also be detached in case permanent stent placement is needed. Retrievable SES are being used in Europe and currently tested in clinical trials in the United States. We review the recent literature in the use of stents for the treatment of AIS secondary to large vessel occlusion.

Wingspan experience in the treatment of symptomatic intracranial atherosclerotic disease after antithrombotic failure.

Background and purpose Intracranial stenting with the Wingspan system has been used as a revascularization strategy in symptomatic patients with intracranial atherosclerotic disease (ICAD). The latest results of the Stenting versus Aggressive Medical Therapy for Intracranial Artery Stenosis (SAMMPRIS) trial challenge this approach. Our experience in the treatment of symptomatic ICAD with the Wingspan system is reported. Materials and methods Patients who underwent stenting for symptomatic ICAD were included in the analysis. Demographic data, periprocedural complications, long term radiological and clinical outcomes are reported. Results 46 lesions were treated in 45 patients. 13 patients (29%) presented with a transient ischemic attack and 32 (71%) with a stroke. 43 patients (95.5%) failed antithrombotic therapy at presentation. One (2%) symptomatic periprocedural (24 h) complication occurred. The 30 day incidence of stroke and vascular death was 6.6%—a fatal hemorrhagic stroke and two non-fatal hemorrhagic strokes. In-stent stenosis (≥50%) was seen in nine (42.8%) lesions, two were symptomatic. Conclusions This cohort of patients with symptomatic ICAD who failed antithrombotic medications benefited from angioplasty and stenting with the Wingspan system.

Spinal arteriovenous malformation associated with spinal metameric syndrome: a treatable cause of long-term paraplegia?

Cutaneomeningospinal angiomatosis, or Cobb syndrome, is a rare metameric developmental disorder presenting as an extradural-intradural vascular malformation that involves bone, muscle, skin, spinal cord, and nerve roots. A 14-year-old girl with a red nevus involving the T6-9 dermatomes on the left side of her back presented with a 5-year history of bowel and bladder incontinence, paraplegia, and lower-extremity sensory loss. Magnetic resonance imaging demonstrated a hemangioma in the T-8 and T-9 vertebral bodies and a spinal cord AVM nidus extending from T-6 to T-9. The AVM was successfully embolized and the patient regained lower-extremity strength, ambulation, and normal sphincter functions after 5 years of having been wheelchair bound. The authors report the restoration of ambulation after endovascular embolization of a large spinal AVM in a patient with long-standing paraplegia due to Cobb syndrome.