Mani Puthuran

Initial experience of coiling cerebral aneurysms using the new Comaneci device

We present our initial patient experience with an innovative temporary bridging device, the Comaneci (Rapid Medical, Israel), to assist in the coiling of cerebral aneurysms. The Comaneci device confers the same benefits as balloon remodeling but without the risks of parent artery occlusion. This alleviates time pressure on the clinician, and could reduce the risk of parent artery thrombosis. Three patients were treated with the Comaneci device. Two patients had acute ruptured posterior communicating aneurysms and one patient was treated electively for a carotico-ophthalmic aneurysm. Excellent occlusion of all three aneurysms was obtained. One patient developed a distal middle cerebral artery clot, that was treated with intravenous aspirin, with minor neurological consequences. These early results show that the Comaneci device can be used to achieve good cerebral aneurysm occlusion. Vessel patency is maintained throughout the procedure with potential advantages over conventional balloon assisted coiling.

Accuracy of four-dimensional CT angiography in detection and characterisation of arteriovenous malformations and dural arteriovenous fistulas.

A retrospective review was made to assess the accuracy of four dimensional CT angiogram (4D-CTA) in diagnosis of arteriovenous malformations (AVM) and dural arteriovenous fistulas (DAVF), with catheter-based digital-subtraction angiogram (DSA) being gold standard. 33 pairs of investigations (DSA and 4D-CTA) were performed primarily for suspicion of AVM/DAVF. Based on blinded reports, sensitivity and specificity for detection of AVM/DAVF were 77% (95% CI: 46 - 95%) and 100% (95% CI: 83 - 100%) respectively. Positive predictive value was 100% (95% CI: 69 - 100%) and negative predictive value 87% (95% CI: 66-97%). 4D-CTA is a practical minimally-invasive technique for evaluating cerebrovascular pathologies. There is good agreement between the findings of 4D-CTA and DSA despite the differences in temporal and spatial resolutions. 4D-CTA may obviate the need for DSA in a subgroup of patients who would otherwise have undergone this invasive investigation, which carries a risk of important complications.

Distal access using hyperflexible atraumatic distal tip with optimized proximal stability of the Benchmark intracranial guide catheter for the treatment of cerebral vascular diseases: a technical note

Background A stable guide catheter position within the intracranial vasculature is critical for safe, successful endovascular treatment. Objective To present ourinitial experience with the 0.071 inch inner diameter Benchmark guide catheter used in the treatment of intracranial cerebrovascular pathologies, demonstrating its safety and efficacy. Methods We retrospectively reviewed use of the Benchmark guide catheter from September through December 2014 in the management of various neuroendovascular intracranial pathologies. Clinical performance and complication rates were evaluated, with particular consideration of vessel tortuosity. A total of 62 Benchmarks were used, 47 in the anterior circulation, 10 in the posterior circulation, 4 in the external carotid, and 1 in the venous sinus. The five cases with access to the external carotid and venous sinus were excluded. Results The Benchmark was able to cross at least one 90° turn in 49 (86%) of the 57 patients. Reversal of the catheter was seen in 15% of 47 anterior circulation cases (4 at one 90° turn; 3 at two 90° turns). We report no complications of dissection or thromboembolic events. All guide catheter positions were safely achieved over a 0.035 Terumo stiff glidewire without need for an inner smaller lumen guide catheter for navigation. Conclusions Benchmark is a new guide catheter, with an ideal combination of both hyperflexible, atraumatic distal tip and optimized proximal shaft support to provide stable 6F primary access for a successful neurointerventional procedure. Benchmark can be easily, safely, and consistently positioned in a desired location within intracranial arteries providing a stable position for intervention and adequate angiography.

Novel use of 4D-CTA in imaging of intranidal aneurysms in an acutely ruptured arteriovenous malformation: is this the way forward?

Ruptured arteriovenous malformation (AVM) is a frequent cause of intracranial hemorrhage. The presence of associated aneurysms, especially intranidal aneurysms, is considered to increase the risk of re-hemorrhage. We present two cases where an intranidal aneurysm was demonstrated on four-dimensional CT angiography (time-resolved CT angiography) (4D-CTA). These features were confirmed by digital subtraction angiography (catheter arterial angiogram). This is the first report of an intranidal aneurysm demonstrated by 4D-CTA. 4D-CTA can offer a comprehensive evaluation of the angioarchitecture and flow dynamics of an AVM for appropriate classification and management.

PO262 Endovascular stroke treatment, a new era – cheshire & merseyside regional experience

The stroke treatment world wide has seen a giant leap in last few years as the science has moved from systemic infusion of clot busting drugs to highly selective intra arterial intervention. The intervention requires careful selection of subset of stroke secondary to large vessel occlusion in a timely fasshion. Since the publication of MR CLEAN ( Multicenter Randomised CLinical trial of Endovascular treatment for acute ischaemic stroke in the Netherlands) trial in 2014 and recent NICE approval to provide this service UK wide stroke services will face challanges to provide this in an equitable fashion. We at Walton Centre have been providing this service to the whole of Cheshire, Merseyside since 2013. Through this audit we would like to share our experience of stroke intervention in this stand alone neurosciences centre. This audit compared the standards against the European Stroke organisation guidelines for ischaemic stroke 2016. We measured the following key parameters along with clinical outcome. 1) Does recanalisation influence immediate neurological recovery. 2) Does bridging thrombectomy (IV thrombolysis +thrombectomy) differ from primary thrombectomy. 3) Does performing the service out of hours influence the outcome

Recurrent life-threatening haemoptysis from a bleeding vertebral artery pseudoaneurysm: A diagnostic dilemma

A bleeding vertebral artery pseudoaneurysm is a rare cause of haemoptysis. Pseudoaneurysm can arise due to radionecrosis from previous radiotherapy in the base of skull and neck region and may present with haemoptysis many years later. It is important to be aware of this entity in the work-up of haemoptysis, particularly in patients with previous base of skull and neck radiotherapy. Our patient was successfully treated with endovascular occlusion.

Endovascular treatment considerations in Idiopathic Intracranial Hypertension (IIH)

Impaired cerebral venous sinus outflow leading to cerebral venous hypertension has been implicated as a potential final common pathway in the pathophysiology of idiopathic intracranial hypertension (IIH). The aim of this study is to assess the role of endovascular management strategies in the form of either primary venous sinus angioplasty or venous stenting for refractory IIH.

Complications of Aneurysm Coiling

Endovascular coiling of intracranial aneurysm is an accepted treatment with good outcome and long-term efficacy. However like any interventional technique, it has procedural risks and complications. Large studies have shown a procedural complication rate leading to morbidity and mortality of around 5–6 %. Thromboembolic events followed by procedural rupture account for the majority of complications.

E-076 Fistulae at the Falx and Tentorium cerebelli; Liverpool series

Dural arteriovenous fistulae at the falx and at the an terior and posterior margin of the tentorium cerebelli drain into cortical veins exclusively and their most common mode of presentation is haemorrhage. The concept of dural fistulae that involve smaller sinuses at the tent and falx was introduced by PICARD (1990, Journal of Neuroradiologie 17,161–181). We have retrospectively analysed a series of patients treated in between 2002 and 2012. 12 were found to be located at the falx and 30 located at the tent. One patient with an unruptured fistula died before treatment because of a haemorrhage. All other patients except one were treated initially with embolisation via feeding meningeal arteries with Onyx. This lead to radioanatomic cure in all but sixth patients. In the completely obliterated we observed that during this single feeder injection of Onyx 20 or 34 led to penetration to the origin of the first draining vein at the tentorial or falcine sinus and could then, with continued injection, retrogradely penetrate into the distal parts of the other feeding arteries leading to complete arterial disconnection from the venous side. In two patients for safety reasons to block retrograde embolisation of the internal carotid artery via the artery of Bernasconi, the internal carotid artery was temporarily blocked with a balloon at the origin of this branch during injection. One patient primarily and 3 others were then successfully occluded by surgery, the remaining by an endovascular transvenous approach with injection of Onyx. No lethal or complications with persistent disabling morbidity were recorded. Disclosures H. Nahser: 6; C; Support for Travel to meetings by various companies. M. Puthuran: 6; C; Support for Travel by various companies. A. Chandran: None. M. Javadpour: 6; C; Support for Travel to meetings by various companies. P. Eldridge: 6; C; support for Travel to meetings by various companies.