Kenneth Fraser

Percutaneous transthoracic needle biopsy of the lung: review of 612 lesions.

PURPOSE The results and complications of 651 pulmonary fine-needle aspiration biopsies (FNABs) were reviewed. The number of needle passes and needle size were correlated to pneumothorax and chest tube placement rates. MATERIALS AND METHODS FNAB of the lung was performed on 651 occasions in 612 patients with 18- to 22-gauge Franseen needles. Diagnostic rates were calculated. The number of needle passes performed and needle size used were evaluated for their association with pneumothorax and subsequent chest tube placement. RESULTS Diagnostic accuracy was 94% with sensitivity for malignancy of 95%. Positive and negative predictive values were 99.5% and 90%, respectively. Pneumothorax occurred in 26.9% of patients with 9.2% requiring chest tube placement. Increasing numbers of needle passes and larger needle sizes did not increase the rates of pneumothorax or chest tube placement. CONCLUSIONS FNAB of the lung has excellent diagnostic rates and remains the procedure of choice for diagnosing pulmonary lesions. This large study contradicts perceptions that pneumothorax and chest tube placement rates decrease with thinner needles and fewer passes.

Emerging Concepts in the Treatment of Intracranial Aneurysms: Stents, Coated Coils, and Liquid Embolic Agents

ENDOVASCULAR TECHNIQUES FOR the treatment of intracranial aneurysms are rapidly evolving. Modifications of more traditional coils have been introduced. Such modifications include newer coils coated with various polymers to increase both coil thrombogenicity and degree of aneurysm packing. In addition, newer coil designs aimed at improving the conformability of the coil to the aneurysm have been used with promising preliminary results. The availability of a newer generation of stents specifically designed for intracranial navigation allows for more effective treatment of aneurysms with wide necks, which usually have been considered unsuitable for optimal endovascular treatment. Endovascular alternatives to coil embolization, such as liquid embolic materials, also have been explored for the treatment of intracranial aneurysms, with varying results. We summarize the rationale for use of these newer devices and early clinical experiences. Areas of current research and future directions of endovascular aneurysm treatment also are discussed.

The occipital artery: a microanatomical study.

OBJECTIVE: We performed a systematic microanatomical study of the occipital artery (OA) and its branches to describe the course, diameter, and branches of this vessel as well as the presence and pattern of anastomotic channels between the OA and the vertebral artery. METHODS: Twelve occipital arteries (6 adult cadaveric heads injected with colored latex) were studied using the surgical microscope. Particular attention was given to the course and branching pattern of the artery as well as the presence and type of anastomotic channels between the occipital artery and vertebral artery. RESULTS: Based upon anatomical considerations, the course of the occipital artery was divided into three segments. The first, or digastric segment, extends from the origin to the exit off the occipital groove of the mastoid process. The second segment, or suboccipital, extends from the occipital groove to the superior nuchal line. The third, or terminal segment, corresponds to the subgaleal segment just above the superior nuchal line up to the vertex. Two main descending branches of the second segment or suboccipital were identified. The superficial descending branch (SDB) runs between the splenium capitis and semispinalis capitis while the deep descending branch (DDB) enters the suboccipital triangle. Anastomotic vessels between one of these two descending branches and branches of the vertebral artery were found in 11 out of the 12 OAs dissected (91%). CONCLUSION: Detailed knowledge of the OA anatomy is helpful in choosing this vessel as a donor for extra-intracranial bypasses. More importantly, knowledge and understanding of the type and pattern of anastomoses between the OA and the vertebral artery are critical to avoid disastrous complications (i.e., posterior circulation stroke) during embolization of vascular or neoplastic processes fed by distal OA branches.

Emergent Combined Intracranial Thrombolysis and Carotid Stenting in the Hyperacute Management of Stroke Patients with Severe Cervical Carotid Stenosis

BACKGROUND AND PURPOSE: The timely re-establishment of intracranial perfusion, the effective prevention of early recurrent strokes, and the limitation of the incidence of reperfusion injury are the major factors that are key to successful treatment of patients with hyperacute stroke who had severe ipsilateral cervical internal carotid artery (ICA) stenosis. In an effort to reduce both the extent of the ongoing neurologic injury and the risk of early recurrent stroke, we have adopted an aggressive combined endovascular approach of intracranial thrombolysis and cervical carotid stent placement during the hyperacute phase. We report on the results of 5 such consecutive patients who presented to our center from January 2003 through January 2005. MATERIALS AND METHODS: From January 2003 through January 2005, 5 consecutive patients presented to our center with hyperacute strokes and severe ipsilateral cervical ICA stenosis. All were treated with emergent carotid stent placement and intra-arterial thrombolysis. The medical records were reviewed and summarized. RESULTS: One patient died. The remaining 4 patients had an average hospital stay of 4 days (range, 3–5 days) and a mean National Institutes of Health Stroke Scale (NIHSS) score of 2 (range, 0–3) at the time of discharge. With a mean clinical follow-up of 11 months (range, 6–24 months), all had excellent functional outcome with a modified Rankin score of 0 or 1. CONCLUSIONS: Data on emergent carotid stent placement in the hyperacute management of stroke are limited. The summarized experience in these 5 patients demonstrates the feasibility of this aggressive therapeutic strategy that may bring about a good outcome.

Successful intra-arterial basilar artery thrombolysis in a patient with bilateral vertebral artery occlusion: Technical case report

OBJECTIVE AND IMPORTANCE: Basilar artery occlusion is a clinical event with an exceedingly high mortality rate. Improved survival is closely associated with successful recanalization of the occluded basilar artery. Bilateral vertebral artery occlusion (BVAO) is a unique disease entity that effectively denies any direct access to the basilar artery for endovascular rescue therapy. We report a case of successful intra-arterial basilar artery thrombolysis in a patient with BVAO. CLINICAL PRESENTATION: A 78-year-old man was transferred to our hospital after intravenous administration of tissue plasminogen activator and with deteriorating neurological status requiring intubation. His clinical presentation was highly suggestive of acute basilar artery thrombosis. The cerebral angiogram showed a BVAO and collateral flow reconstituting both distal extracranial vertebral arteries but with significant contrast stasis. There was no retrograde filling of the basilar artery through the only angiographically visible posterior communicating artery. TECHNIQUE: Selective catheterizations of the left occipital artery and the left ascending cervical branch of the thyrocervical trunk were performed to deliver a total of 12 mg of tissue plasminogen activator. At that point, the patient showed significant neurological improvement. The post-tissue plasminogen activator angiogram showed improved flow through the basilar artery. The patient was independent and well at his 1-year follow-up visit. CONCLUSION: Knowledge of potential collateral pathways is important when direct access to the main intracranial vessels is not available. Basilar artery thrombolysis through collateral vessels is clinically effective when a direct approach to the artery is not feasible.

Cerebral vasospasm in patients with unruptured intracranial aneurysms

SummaryIntracranial arterial vasospasm is a typical sequela of subarachnoid haemorrhage. The association between symptomatic vasospasm and unruptured aneurysms has been sporadically presented in the literature. The pathogenesis of this unusual entity is unclear. The published cases were collected in this review and analysed with regard to timing, clinical presentation and possible relationship with surgical factors. We also added an illustrative case which was recently observed in our department.

Transaxillary carotid stenting: Technical case report

OBJECTIVE AND IMPORTANCE: As endovascular neurointerventions continue to evolve rapidly, angioplasty and stenting of both the extracranial and intracranial vessels have become more routine procedures. When the transfemoral approach is contraindicated or technically difficult, familiarity with alternative access techniques becomes essential. We report a successful transaxillary carotid stenting in a patient with an axillary bifemoral bypass graft. CLINICAL PRESENTATION: A 77-year-old man presented with a symptomatic high-grade stenosis (80%) of the left internal carotid artery. Because of the increased risk of general anesthesia related to his advanced age and severe comorbidities, stenting of the left internal carotid artery was considered. A left transaxillary approach was chosen because of the presence of an axillary bifemoral bypass graft. TECHNIQUE: Under ultrasound guidance, the left axillary artery was successfully punctured and cannulated. After a 0.038 Magic Torque wire (Boston Scientific/Medi-Tech, Watertown, MA) was anchored with the tip of the wire in the distal left occipital artery, a 7-French (outer diameter) Vista Bright guiding sheath (Cordis, Miami, FL) was successfully positioned in the mid left common carotid artery, with an MPA catheter (Cordis) used as guiding support. Subsequently, two Precise stents (Cordis) were successfully deployed across the stenosis, yielding a satisfactory angiographic result. CONCLUSION: With proper patient selection and the use of ultrasound guidance during the initial puncture, the transaxillary approach is a safe and technically feasible alternative to the transfemoral approach when performing carotid stenting.

Thrombosed giant intracavernous aneurysm with subsequent spontaneous ipsilateral carotid artery occlusion

SummaryWe report a case of a 47-year-old man with a giant thrombosed aneurysm of the right cavernous internal carotid artery who initially presented with headache, double vision and trigeminal numbness. He experienced subsequent asymtomatic proximal occlusion of the parent vessel, revealed by follow-up angiography. This case illustrates the possibility that a giant thrombosed aneurysm may exert enough compression upon the parent vessel to induce flow stasis with resultant intraluminal thrombosis progressing to occlude the entire parent artery.

Emergent endovascular treatment with direct carotid puncture for exsanguinating carotid blowout syndrome

AbstractIntroduction: Carotid Blowout Syndrome (CBS) carries an exceedingly high mortality rate. Various established endovascular techniques are successful in treating less acute CBS, but exsanguinating patients with hemodynamic compromise continue to pose a significant clinical challenge. Methods: We report a 53-year-old male with squamous cell carcinoma of the anterior tongue presented with a sentinel hemoptysis followed by a massive oral hemorrhage. The patient suffered a cardiac arrest secondary to acute blood loss, from which he was successfully resuscitated. Results: An occlusion technique is presented involving direct carotid puncture for successful treatment of hemodynamically unstable, exsanguinating patients. Conclusion: This technique accomplishes rapid arrest of exsanguination, minimal hemorrhage site manipulation, and successful carotid occlusion.

A case of vestibular and oculomotor pathology from bilateral AICA watershed infarcts treated with basilar artery stenting

Bilateral AICA infarcts may be the result of impaired arterial flow in watershed territories that overlap with PICA and SCA brainstem/cerebellar circulation among patients with critical basilar artery stenosis (1-3). We report one such patient with watershed bilateral AICA infarcts. She had a two-week history of progressive truncal ataxia, frequent falls, dysarthria and episodic vomiting. Examination suggested brainstem/cerebellar localization. She had bilateral symmetric infarcts of the cerebellar flocculus and middle cerebellar peduncles (MCP) due to tandem proximal and mid-basilar artery (BA) stenosis. Failure to improve on maximal medical therapy led to BA angioplasty/ stenting, with improved brainstem/cerebellum circulation and neurologic deficits.