M Chaudry

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.

The golden hour of stroke intervention: effect of thrombectomy procedural time in acute ischemic stroke on outcome

Introduction Outcome studies in acute ischemic stroke (AIS) have focused on time from symptom onset to treatment. The purpose of this study was to investigate whether time to achieve vessel recanalization from groin puncture affects outcomes. Methods We studied all AIS cases that underwent intra-arterial therapy between May 2008 and October 2012 at a high volume center for anterior circulation occlusions. Candidacy for thrombectomy is determined by CT perfusion imaging, irrespective of time of onset. Patients were then dichotomized into two groups: ‘Early recan’ assigned in which recanalization was achieved in ≤60 min from groin puncture and ‘Delayed recan’ in which procedures extended beyond 60 min. Time to recanalize was also studied as a continuous variable. Results 159 patients (53.5% women, mean age 66.4±15.2 years) were identified. The mean National Institutes of Health Stroke Scale (NIHSS) score was similar between ‘Early recan’ patients (16.8±6.1) compared with ‘Delayed recan’ patients (15.4±5.8, p=0.149). Among the ‘Early recan’ patients, recanalization was achieved in 40.7±13.6 min compared with 101.7±32.5 min in the ‘Delayed recan’ patients (p<0.0001). The likelihood of achieving a good outcome (modified Rankin Scale score 0–2) was higher in the ‘Early recan’ group (53.6%) compared with the ‘Late recan’ group (30.8%; p=0.009). On logistic regression analysis, time to recanalization from groin puncture, baseline NIHSS, revascularization, diabetes, and hemorrhages were found to significantly impact on outcome at 90 days, as measured by the modified Rankin Scale. Conclusions Our findings suggest that extending mechanical thrombectomy procedure times beyond 60 min increases complications and device cost rates while worsening outcomes. These findings can serve as a time frame of when it is prudent to abort a failed thrombectomy case.

Initial multicenter technical experience with the Apollo device for minimally invasive intracerebral hematoma evacuation.

BACKGROUND: No conventional surgical intervention has been shown to improve outcomes for patients with spontaneous intracerebral hemorrhage (ICH) compared with medical management. OBJECTIVE: We report the initial multicenter experience with a novel technique for the minimally invasive evacuation of ICH using the Penumbra Apollo system (Penumbra Inc, Alameda, California). METHODS: Institutional databases were queried to perform a retrospective analysis of all patients who underwent ICH evacuation with the Apollo system from May 2014 to September 2014 at 4 centers (Medical University of South Carolina, Stony Brook University, University of California at San Diego, and Semmes-Murphy Clinic). Cases were performed either in the neurointerventional suite, operating room, or in a hybrid operating room/angiography suite. RESULTS: Twenty-nine patients (15 female; mean age, 62 ± 12.6 years) underwent the minimally invasive evacuation of ICH. Six of these parenchymal hemorrhages had an additional intraventricular hemorrhage component. The mean volume of ICH was 45.4 ± 30.8 mL, which decreased to 21.8 ± 23.6 mL after evacuation (mean, 54.1 ± 39.1% reduction; P < .001). Two complications directly attributed to the evacuation attempt were encountered (6.9%). The mortality rate was 13.8% (n = 4). CONCLUSION: Minimally invasive evacuation of ICH and intraventricular hemorrhage can be achieved with the Apollo system. Future work will be required to determine which subset of patients are most likely to benefit from this promising technology. ABBREVIATIONS: GCS, Glasgow Coma Scale ICH, intracerebral hemorrhage IVH, intraventricular hemorrhage tPA, tissue plasminogen activator

Novel device and technique for minimally invasive intracerebral hematoma evacuation in the same setting of a ruptured intracranial aneurysm: combined treatment in the neurointerventional angiography suite.

BACKGROUND: The presence of intracerebral hematoma from aneurysm rupture is an indication for craniotomy for clot evacuation and aneurysm clipping. Some centers have begun securing aneurysms with coil embolization followed by clot evacuation in the operating room. This approach requires transporting a patient from the angiography suite to the operating room, which can take valuable time and resources. OBJECTIVE: To report our experience with 3 cases in which a novel technique for minimally invasive evacuation of intracerebral hematomas after endovascular treatment of ruptured intracranial aneurysms was used. The Penumbra Apollo system can be used in the angiography suite in conjunction with neuroendovascular techniques to simultaneously address a symptomatic hematoma associated with a ruptured aneurysm. METHODS: Standard preoperative computed tomography angiography was performed on arrival to the emergency department. The patients underwent diagnostic cerebral angiography followed by balloon-assisted coil embolization and then remained in the neurointerventional suite for intracerebral hematoma evacuation with the Apollo system. RESULTS: All patients tolerated coil embolization and hematoma evacuation well. The combined procedures lasted <3 hours in both cases. Two patients were eventually discharged to acute rehabilitation facilities less than a month after their initial insult, and 1 has been cleared to return to work. The other patient was transferred to hospice care. CONCLUSION: The Apollo aspiration system appears to be a safe and effective minimally invasive option for intracerebral hematoma evacuation, particularly when coupled with endovascular embolization of ruptured intracranial aneurysms. Future work will address which patient population is most likely to benefit from this promising technique. ABBREVIATION: ICH, intracerebral hematoma

An Update on the Adjunctive Neurovascular Support of Wide-Neck Aneurysm Embolization and Reconstruction Trial: 1-Year Safety and Angiographic Results

BACKGROUND AND PURPOSE: The safety and efficacy of the PulseRider for the treatment of wide-neck, bifurcation aneurysms at the basilar and carotid terminus locations were studied in a prospective trial, the Adjunctive Neurovascular Support of Wide-Neck Aneurysm Embolization and Reconstruction (ANSWER) trial, reporting on initial 6-month angiographic and clinical results. This report provides insight into the longer term durability and safety with 12-month data. MATERIALS AND METHODS: Aneurysms treated with the PulseRider among enrolled sites were prospectively studied. Updated 12-month data on clinical and imaging end points are included. RESULTS: Thirty-four patients were enrolled (29 women, 5 men) with a mean age of 60.9 years. The mean aneurysm height ranged from 2.4 to 15.9 mm with a mean neck size of 5.2 mm (range, 2.3–11.6 mm). At 1 year, there were no device migrations or symptomatic in-stent stenoses. Raymond-Roy I occlusion was achieved in 53% of cases at the time of treatment and progressed to 61% and 67% at 6 and 12 months, respectively. Adequate occlusion (Raymond-Roy I/II) progressed from 88% at 6 months to 90% at 12 months. No recanalizations were observed. There was 1 delayed ischemic event. Good outcome (mRS 0–2) was achieved in 90% of patients. CONCLUSIONS: The updated 1-year results from the ANSWER trial demonstrate aneurysm stability and an acceptable safety profile for aneurysms treated at the basilar apex and carotid terminus. Prospective data from a larger set of aneurysms treated at other locations are required to assess how treatment with PulseRider compares with alternatives for treating wide-neck bifurcation aneurysms.

O-008 The Financial Impact of ADAPT for Endovascular Treatment of Acute Ischemic Stroke

Introduction The use of mechanical thrombectomy for treatment of acute ischemic stroke has significantly advanced over the last 5 years. Little data is available analysing the cost relative to the clinical and angiographic outcomes. The aim of this study is to analyze the cost and efficacy of current stroke therapy. Methods A retrospective review of the chart and hospital financial database of all ischemic stroke cases from 2009–2013 was performed. Three discreet treatment methodologies evolved during this time: traditional Penumbra System (PS), stent retriever with local aspiration (SRLA) and A Direct Aspiration first Pass Technique (ADAPT). Statistical analysis of clinical and angiographic outcomes and costs for each group was performed. Results 222 patients (45% male) underwent mechanical thrombectomy, with 88% of strokes present in the anterior circulation. PS was used 58%, SRLA 13% and ADAPT in the remaining 29% of cases. PS was able to achieve TICI2b/3 revascularization 79%, SRLA was effective 83% and ADAPT 95% of the time. The average total cost of hospitalization for patients treated with PS was

Evaluation of the Nfocus LUNA, a new parent vessel occlusion device: a comparative study in a canine model.

51,599, SRLA was

P-029 Use of the Sceptre C Dual-Lumen Balloon Microcatheter in Onyx Embolization of Cerebral Arteriovenous Malformations: A Multi-Center Experience

54,700 and ADAPT

E-019 Novel aneurysm neck reconstruction device: initial experience in an experimental pre-clinical bifurcation aneurysm model: Abstract E-019 Figure 1

33,611 (p < 0.0001). The average length of stay was significantly less for ADAPT (7 days) than PS (10.6 days), but not for SLRA (8.3 days) (p = 0.02). Average time to recanalization for PS was 88 min, SRLA was 47 min and ADAPT was 37 min (p < 0.0001). Similar rates of good neurologic outcomes were seen in group PS (36%) as group SRLA (43%) and ADAPT (47%) (p = 0.4). Conclusion The most cost effective approach to a large intracranial vessel occlusion appears to be direct aspiration with a large bore catheter (without the separator) first and if this fails then proceed with other devices such as a stentriever. Disclosures A. Turk:1; C; Stryker, Microvention, Penumbra. 2; C; Stryker, Microvention, Covidien, Penumbra, Siemens. 3; C; Stryker, Microvention, Covidien, Siemens, Penumbra. R. Turner: 1; C; Penumbra, Microvention, Stryker. 2; C; Penumbra, Microvention, Stryker. 3; C; Penumbra, Microvention, Stryker. M. Chaudry: 1; C; Penumbra, Microvention, Stryker. 2; C; Penumbra, Microvention, Stryker. 3; C; Penumbra, Microvention, Stryker. A. Spiotta: 1; C; Penumbra, Microvention, Stryker. 2; C; Penumbra, Microvention, Stryker. 3; C; Penumbra, Microvention, Stryker.

P-010 Initial US experience with detachable tip microcatheter for arteriovenous malformations

BACKGROUND: Parent artery occlusion is sometimes required to treat cerebrovascular lesions. OBJECTIVE: We evaluated the Nfocus LUNA parent vessel occlusion (PVO) device in comparison with the Vascular Plug (AVP) used in the peripheral vasculature for large-vessel occlusion in a canine animal model. METHODS: The subclavian arteries were targeted for occlusion in 7 canines. Each animal received 1 LUNA and 1 AVP device sequentially rotated between the left and right subclavian arteries. Angiographic assessment was performed serially after device placement until vessel occlusion was observed and then again immediately before the animal was killed. Three animals were euthanized at 1 month and 4 at 2 months post-implantation, after which the native artery segments containing the implanted device were harvested and preserved for subsequent histological analysis. RESULTS: The LUNA PVO device and the AVP were accurately positioned and deployed in all cases. Acute occlusion times for the devices were not statistically different. In no instance was there any evidence of device migration. At 28 and 55 days, the LUNA implants showed nearly complete occlusion with small recanalization channels, whereas the AVP devices were associated with low occlusion levels and large residual vascular channels within the occluder. CONCLUSION: The LUNA PVO device and delivery system can be accurately placed to occlude vessels without migration and with a performance that is similar to the AVP. The LUNA PVO device on average provided a higher degree of occlusion durability at both 1 and 2 months.