Jonathan Lena

Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke

Introduction A tandem occlusion is a rare presentation of acute stroke that involves an occlusion of the internal carotid artery at the bifurcation with an intracranial middle cerebral artery occlusion. This study describes the experience at our institution in treating tandem occlusions with a proximal to distal approach in the acute stroke setting. Methods A retrospective review of acute strokes caused by tandem occlusions requiring thrombectomy were performed. Results 16 cases were identified with a mean National Institutes of Health Stroke Scale score at presentation of 13.1±3.9. The proximal occlusion was crossed initially with a microwire in all cases. All carotid occlusions were treated with stenting, and intracranial vessel thrombectomy was performed with a variety of devices. Procedure related complications occurred in two (12.5%) patients. Eight patients (50%) achieved a good outcome (modified Rankin Scale score of 0–2). Conclusions A tandem occlusion of the carotid artery at the bifurcation with a concomitant intracranial occlusion is a relatively rare and complex presentation of acute stroke. We have found that addressing the proximal lesion first and covering it with a stent prior to performing distal thrombectomy appears to be a safe and effective option in the treatment algorithm.

A survey of neurointerventionalists on thrombectomy practices for emergent large vessel occlusions

Background The effect of the five positive randomized controlled trials on thrombectomy practices and procedural volume has yet to be defined. Further, few studies have attempted to define modern thrombectomy practices in terms of selection criteria and devices used. Methods A 21 question survey of Society of Neurointerventional Surgery (SNIS) physicians was administered using the SurveyMonkey website, addressing current practices as well as changes from before January 1, 2015 to the months after this date. Results A total of 78 responses were obtained (approximately 10% of SNIS membership). Prior to January 2015, two-thirds of respondents reported performing 1–5 thrombectomies per month (67%), with 31% performing more than 5 per month. Following January 2015, 62% of respondents reported performing more than 5 thrombectomies per month; 45% of respondents reported a higher number of thrombectomies after trial publication. 73% and 80% of respondents indicated that inpatient consultations and hospital to hospital transfers for thrombectomy have increased, respectively. A plurality of respondents reported using A Direct Aspiration First Pass Technique (40%) as the first strategy for revascularization. Most commonly, neurointerventionalists reported using conscious sedation (56%) for anesthesia. 74% of respondents indicated being successful with their primary technique in at least 70% of cases. Conclusions This survey of predominantly academic SNIS physicians indicates that inpatient consultations, hospital to hospital transfers, and thrombectomy procedural volumes have increased modestly since the publication of the five major stroke trials this year. In addition, many respondents indicated an increase in aggressiveness in pursuing thrombectomy based on selection criteria.

Y-Stenting for Bifurcation Aneurysm Coil Embolization: What is the Risk?

The use of two stents in a “Y” configuration (Y-stenting) to assist with coil embolization of complex bifurcation aneurysms has been accepted as an alternative to clip reconstruction of a select subset of challenging aneurysms. We review the risks associated with Y-stenting, including its procedural complication rates, angiographic occlusion rates, rerupture, and retreatment rates.

Percutaneous ethanol embolization and cement augmentation of aggressive vertebral hemangiomas at two adjacent vertebral levels

This report describes a case of successful percutaneous direct-puncture ethanol embolization, followed by vertebroplasty, of an aggressive vertebral hemangioma (VH) involving two adjacent thoracic vertebral levels. In this case, the 78-year-old male patient presented with a 6-month history of progressive paraparesis due to spinal cord compression by a T8-T9 VH with an extensive epidural component. Follow-up demonstrated epidural component shrinkage with complete regression of symptoms at 3 months. This case suggests that exclusive percutaneous treatment may be considered for symptomatic VH even when two adjacent vertebral levels are affected.

Stent-assisted coiling of cerebral aneurysms: a single-center clinical and angiographic analysis

Objective This study retrospectively compared the clinical and angiographic outcomes of treating cerebral aneurysms with Neuroform (NEU), Enterprise (EP), and Low-profile Visualized Intraluminal Support (LVIS/LVIS Jr) stents. Materials and methods We conducted a retrospective analysis of a procedural database. All aneurysm procedures using any of the three types of self-expanding nitinol stents (NEU, EP and LVIS/LVIS Jr) were included. Intra-procedure complications, post-procedure complications, and angiographic results (Raymond–Roy grade scale, RRGS) were analyzed retrospectively. A multivariate logistic regression analysis was conducted to identify predictors of intra-procedure and post-procedure complications. Results Two hundred and forty-three aneurysms in 229 patients treated with stent-assisted coiling were included (NEU group: 109 aneurysms; EP group: 61 aneurysms; LVIS/LVIS Jr: 73 aneurysms). The LVIS/LVIS Jr group was associated with the lowest rate of initial complete occlusion (RRGS I: 47.9%; 35/73). Follow-up showed the proportion of RRGS I increased for all stent groups but was greatest in the LVIS/LVIS Jr group. Overall, 17 intra-procedural complications were seen in 229 patients (7.4%) and 15 post-procedural complications were found in 198 patients at follow-up (7.6%), with no differences between stent groups. Thrombotic events were the most common complications and occurred in 13 patients (13/229, 5.7%). Conclusions All three types of stents used to treat cerebral aneurysms with unfavorable neck were safe and effective, providing suitable support for the coil mass. LVIS/LVIS Jr promotes better progressive aneurysm complete occlusion than the other two stents but seems to cause more common intra-procedural stent-related thrombotic events and fewer post-procedural complications.

Comparison of venous sinus manometry gradients obtained while awake and under general anesthesia before venous sinus stenting

Introduction Venous sinus stenting is a popular treatment strategy for patients with high venous sinus pressure gradients across a site of outflow obstruction. Little is known about the effect of anesthesia on venous sinus pressure measurements. Objective To compare venous manometry performed in patients under general anesthesia and while awake. Methods A prospective database was accessed to retrospectively identify patients who had undergone venous sinus stenting. Pressure gradients were compared between those patients who underwent manometry while awake and before stenting under general anesthesia. Results Thirty patients with both general anesthesia and awake pressure recordings were identified. Pressure measurements were highly variable but overall were higher under general anesthesia by an average of 5.8 mm Hg (1.7; p=0.002). A significant difference between awake and general anesthesia pressure measurements was detected in the sigmoid sinus (5.8 mm Hg (2.0); p=0.005) and the jugular vein (8.1 mm Hg (3.9); p=0.040). Only 11/30 (36.7%) pressure gradients remained within 5 mm Hg of the original awake gradient when repeated under general anesthesia; 9/30 (30%) patients had gradients that were at least 10 mm Hg different across procedures. Conclusions Calculated pressure gradients were markedly affected by anesthesia. These findings suggest that candidacy for stenting should be determined with venous manometry while patients are awake owing to the unpredictable and highly variable effect of general anesthesia on pressure measurements and an apparent tendency to underestimate the degree of venous outflow obstruction.

Equivalent favorable outcomes possible after thrombectomy for posterior circulation large vessel occlusion compared with the anterior circulation: the MUSC experience

Introduction In acute ischemic stroke (AIS), posterior circulation large vessel occlusions (LVOs) have been associated with poorer outcomes compared with anterior circulation LVOs. The outcomes of anterior versus posterior circulation thrombectomy for LVOs were compared at a high volume center employing a direct aspiration first pass technique (ADAPT). Methods We retrospectively studied a database of AIS cases that underwent ADAPT thrombectomy for LVOs. Cases were grouped by anatomical location of thrombectomy (posterior vs anterior circulation), and analysis was performed on both entire sample size. Results A total of 436 AIS patients (50.2% women, mean age 67.3 years) underwent ADAPT thrombectomy for LVO during the study period, of whom 13% of had posterior circulation thrombectomy. Patients with posterior circulation thrombectomy did not show a significant difference in preprocedural variables, including age, baseline National Institutes of Health Stroke Scale (NIHSS), and onset to groin time, compared with anterior circulation (P>0.05). There were also no differences in procedural variables between the two groups. Patients in the posterior group were found to have a similar likelihood of good outcome (modified Rankin Scale score 0—2) at 90 days compared with the anterior group (42.9% vs 43.2%, respectively), and a small but not significant increase in mortality at 90 days. Multilogistic regression analysis showed that the anatomical location (anterior vs posterior) was not an independent predictor of good outcome or mortality after thrombectomy. Prominent predictors of outcome/mortality included age, female gender, procedure time, and baseline NIHSS. Conclusions Our findings demonstrate that when patients are carefully selected for thrombectomy, those with posterior circulation LVOs can achieve similar outcomes compared with anterior circulation thrombectomy, indicating comparable safety and efficacy profiles.

Basilar artery occlusion in a child treated successfully with mechanical thrombectomy using ADAPT

Acute ischemic stroke (AIS) in the pediatric population is rare. Furthermore, it is common for physicians to take significantly longer diagnosing a posterior circulation stroke in a child than in an adult. There are increasing case reports in the literature of treating AIS in children with intravenous tissue plasminogen activator, intra-arterial thrombolysis, and/or mechanical thrombectomy. We present the first case of pediatric AIS treated using a direct aspiration first pass technique (ADAPT) as a means of mechanical thrombectomy.

E-029 Progressively soft coils for treatment of intracerebral aneurysms – an initial experience with the smart coil at two centers

Introduction Endovascular therapy for cerebral aneurysms has increasingly been adopted as a viable treatment strategy for its minimally invasive but effective approach. This rising adoption has been correlated with an evolution in coil technology, including the recently FDA-cleared SMART Coil. In contrast to traditional bare metal coils, which have historically been designed with a uniform degree of softness, SMART Coils are designed with transitional softness, allowing the coil to become progressively softer as it is deployed. This mitigates catheter kickback while enabling the coil to pack more tightly and achieve greater packing density. Herein, we present our initial technical experience on aneurysm obliteration with SMART Coils. Methods Following IRB approval, a retrospective review was conducted at 2 centers to identify consecutive patients presenting with cerebral aneurysms wherein at least 1 SMART Coil was employed as intervention. Patient characteristics, procedural metrics, angiographic outcome, and procedural outcome data were captured to evaluate the safety and efficacy of the use of SMART Coils. Adverse events were classified as major or minor, depending upon whether additional intervention was needed (major). Occlusion outcome was graded using the Raymond Roy Occlusion Classification, in which Class I was complete obliteration, and Class III denotes residual aneurysm. Results Between July 2015 and January 2016, 59 patients were identified wherein embolization was performed with at least 1 SMART Coil; 44% presented with ruptured aneurysms. The mean aneurysm size was 5.9±2×4.5±2 mm, with an average neck diameter of 3.4±1 mm. In total, 54.2% of patients were treated exclusively with SMART Coils while the remainder used various framing or finishing coils. Balloon-assisted coiling was employed in 33.9%, and stent-assisted coiling in 47.5% of all cases. More specifically, in patients wherein SMART Coils were used exclusively, 34.4% were treated with balloon assistance, and 43.4% employed stent-assisted coiling. In the remaining patients, these rates were 77.8% and 51.9%, respectively, for balloon and stent-assisted coiling. Minor adverse events occurred in 10.1%, and included thrombus formation along the coil mass (n=4), thrombus formation within the stent (n=2), and coil prolapse (n=2); none resulted in sequelae. No major adverse events observed. On average, 6.4 ±4 coils were deployed per aneurysm, with a mean fluoroscopy time of 48.5±22 min. Occlusion outcomes included Class I in 33.9%, Class II in 37.3% and Class III in 28.8%. No rebleeds have been observed. Conclusion The progressive design of SMART Coils offered appreciable clinical advantages during deployment. In addition, SMART demonstrated satisfactory safety and efficacy outcomes in treatment of a wide variety aneurysms, both ruptured and unruptured. Abstract E-029 Table 1 Comparison of aneurysm characteristics, treatment, and outcome SMART Exclusively n=32 SMART with other Devices n=27 Ruptured, n (%) 15 (46.9%) 12 (44.4%) Aneurysm Size, mm 5.9 × 4.2×5.7 5.1 × 4.9×4.9 Stent-Assisted Coiling, n (%) 14 (43.8%) 14 (51.9%) Balloon-Assisted Coiling, n (%) 11 (34.4%) 21 (77.8%) Raymond Roy Classification (n (%)) I 9 (28.1%) 11 (40.7%) II 12 (37.5%) 10 (37.0%) III 11 (34.4%) 6 (22.2%) Disclosures A. Spiotta: 1; C; Penumbra, Inc.. 2; C; Penumbra, Inc. 4; C; Penumbra, Inc. K. Fargen: None. J. Lena: 2; C; Penumbra, Inc. I. Chaudry: 1; C; Penumbra, Inc. 4; C; Penumbra, Inc. R. Turner: 1; C; Penumbra, Inc. 4; C; Penumbra, Inc. A. Turk: 1; C; Penumbra, Inc. 4; C; Penumbra, Inc.. D. Huddle: None. L. David: None. R. Bellon: None. D. Frei: 2; C; Penumbra, Inc., Codman, Microvention, Stryker, Siemens, Codman, Microvention, Stryker, Siemens. 4; C; Penumbra, Inc.

E-017 Emergency Onyx embolization of avulsed basilar artery perforator following an endoscopic colloid cyst resection

Introduction Endoscopic resection of a colloid cyst and third ventriculostomy is a well described neurosurgical procedure and is performed commonly. Inadvertent vascular injury can occur due to the limited peripheral field of view offered by the endoscope. We present a case of colloid cyst resection and third ventriculostomy where neurological decline occurred during anesthesia emergence and imaging demonstrated active basilar perforator extravasation on CT angiography (CTA) which was treated with emergency embolization. Case presentation A 23-year-old man presented with headaches. He was found to have hydrocephalus due to a third ventricular colloid cyst. The patient underwent endoscopic resection and third ventriculostomy. During emergence, the patient was found to have a dilated right pupil. A ventriculostomy drain was placed and the patient underwent emergent CT/CTA which demonstrated intraventricular and pre-pontine hemorrhage with active extravasation. The patient underwent emergency angiography which demonstrated active contrast extravasation from a right P1 thalamoperforator. The vessel was catheterized and embolized with Onyx (eV3, Plymouth, Minnesota, USA) (Abstract E-017 figure 1).Abstract E-017 Figure 1 Results There was immediate cessation of extravasation. The patient recovered and was following commands and getting out of bed. He had a complicated clinical course and subsequently developed meningitis and infarcts of his right middle cerebral artery territory and left basal ganglia from vasospasm. His prolonged hospital course concluded and the patient was discharged to home. Conclusion Vascular injury is a rare but devastating complication of intracranial surgery. This is a unique case where emergent endovascular surgery immediately yielded an optimal angiographic result and provided the patient the best opportunity for recovery.