Mary E. Jensen

Position Statement on Percutaneous Vertebral Augmentation: A Consensus Statement Developed by the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, American Association of Neurological Surgeons/Congress of Neurological Surgeons, and American Society of Spine Radiology

It is the position of the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, American Association of Neurological Surgeons/Congress of Neurological Surgeons, and American Society of Spine Radiology (‘the Societies’) that percutaneous vertebral augmentation with vertebroplasty and kyphoplasty is a safe, efficacious, and durable procedure in appropriate patients with symptomatic osteoporotic and neoplastic fractures when performed in a manner in accordance with published standards.1 2 These procedures are offered only when traditional medical therapy has not provided pain relief or pain is substantially altering the patients lifestyle. With regard to vertebroplasty, multiple case series3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 and retrospective18 19 and prospective20 21 22 23 non-randomized studies have shown a statistically significant improvement in pain and function—particularly with regard to ambulation—and these results have been confirmed in a prospective study with use of a control group24 and in a prospective randomized control study.25 The benefits of vertebroplasty far outweigh its risks and the risks of conservative therapy, and the success rate is consistently high. This procedure is cost-effective because it produces immediate improvement in a patients quality of life, primarily by means of the alleviation of pain and rapid return to ambulation. In addition to reducing the need for costly skilled care, expensive drugs, or orthopedic devices, a return to ambulation is known to reduce adverse outcomes in elderly patients confined to bed.26nnKyphoplasty has been introduced as an alternative approach.27 It is similar to vertebroplasty and has been referred to as ‘balloon-assisted vertebroplasty.’ Kyphoplasty entails the inflation of a percutaneously delivered balloon in the vertebral body followed by the percutaneous injection of bone cement into the cavity created by the balloon. The balloon is intended to restore …It is the position of the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, American Association of Neurologic Surgeons/Congress of Neurologic Surgeons, and American Society of Spine Radiology (“the Societies”) that percutaneous vertebral

Position statement on percutaneous vertebral augmentation: a consensus statement developed by the Society of Interventional Radiology (SIR), American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), American College of Radiology (ACR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), Canadian Interventional Radiology Association (CIRA), and the Society of NeuroInterventional Surgery (SNIS).

Radiological Associa Radiology (M.D.K.), U Angeles; Departmen Diego, Medical Cen (M.E.J.), University o sion of Neurointerv Hospital, Boston, M (J.K.M.), Riverside M and Neurological Ins lenburg Radiology A ment of Radiology (A Neurological Surgery and Surgeons; Depa York–Presbyterian H York; Department of Chicago, Illinois; Iow Radiology Associates ment of Radiology (S kee, Wisconsin; D Christiana Care Healt (J.F.C.), Geisinger H Radiology (P.L.M.), V STANDARDS OF PRACTICE

Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization

Background Endovascular treatment of wide-necked aneurysms is challenging. Stent-assisted coiling (SAC) is associated with increased complications and requires dual antiplatelet therapy. Objective To compare treatment of unruptured, wide-necked aneurysms with a dual-microcatheter technique (DMT) versus SAC. Methods Between 2006 and 2011, 100 patients with unruptured wide-necked intracranial aneurysms were treated with DMT and 160 with SAC. Over time there was a significant decrease in the use of SAC and a corresponding increase in DMT. The investigators matched 60 patients treated with DMT blinded to outcome in a 1:2 fashion based on maximal aneurysm dome diameter with 120 patients treated with SAC. Outcomes were determined with conditional (matched) multivariate analysis. Results There were no significant differences in patient or aneurysm characteristics between cohorts, including aneurysm diameter, neck width, or volume. Overall packing density and coil volume achieved was not significantly different between cohorts. There were higher rates of overall complications in those receiving SAC (19.2%) compared with DMT (5.0%; p=0.012), but no significant difference in major complications (8.3% vs 1.7%, respectively; p=0.103). At a mean follow-up of 27.0±18.9u2005months, rates of retreatment did not differ between DMT (15.1%) and SAC (17.7%). Delayed in-stent stenosis occurred in five patients and in-stent thrombosis in four patients treated with SAC. There was no difference in favorable functional outcome (modified Rankin score 0–2) between those treated with DMT (90.6%) compared with SAC (91.2%). Conclusions DMT and SAC are effective endovascular approaches for unruptured, wide-necked aneurysms; however, DMT may result in less morbidity. Further long-term studies are necessary to determine the optimal indications for these treatment options.

Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization

Background and purpose The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. Methods A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. Results On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmologic complications were noted in either cohort. Complete occlusion at 12u2005months was more common following PED treatment than coil embolization (74% vs 47%; p=0.089), although lower than reported in previous trials. This may be due to inflow into the ophthalmic artery keeping the aneurysm patent. Retreatments were more common following coil embolization than PED (24% vs 11%), but this was not significant (p=0.304). Permanent morbidity rates were not significantly different between the PED (11%) and coil embolization (3%) cohorts (p=0.255). Conclusions Our results suggest that ophthalmic artery aneurysms may be adequately and safely treated with either the PED or coil embolization. However, treatment with the PED carries a higher risk of impeding flow to the ophthalmic artery, although this did not result in clinical sequelae in the current study.

Initial Clinical Experience with Biopolymer-coated Detachable Coils (HydroCoil) in Peripheral Embolization Procedures

PURPOSEnTo evaluate the technical and clinical success of HydroCoils in patients who underwent peripheral embolization procedures.nnnMATERIALS AND METHODSnBetween July 2006 and June 2007, 12 peripheral embolization procedures with HydroCoils in 11 patients (six male patients and five female patients; age range, 4-74 years; mean age, 46 y) were available for this retrospective review. The indications for embolization were hemorrhage (n = 4), aneurysm (n = 1), recurrent pulmonary arteriovenous malformation (n = 1), and protection before radioembolization and chemoembolization (n = 5). HydroCoil-10, -14, and -18 systems were used. Procedural and postprocedural follow-up imaging were reviewed by two interventional radiologists. Digital subtraction angiography (DSA) images were used to evaluate embolization success and vessel diameter. DSA and computed tomography (CT) angiography were used for follow-up, which included evaluation for recanalization and migration of coils. Chart review was also performed.nnnRESULTSnAll procedures were successful in occluding the target vessels (100%), which ranged from 1.2 mm to 8.2 mm in diameter (median, 2.2 mm). Immediate clinical success was achieved in all procedures (100%). Follow-up imaging was available in seven cases (four CT angiography and three DSA) at 2-108 days (mean, 42 d). No recanalization or migration of coils was found. There were no procedure-related complications, no clinical evidence of nontarget embolization, and no recurrence of presenting symptoms.nnnCONCLUSIONSnThe use of HydroCoils in peripheral arterial embolization procedures is effective and safe. They are viable alternatives to standard coils, particularly in tortuous, small target vessels or in cases in which controlled release is desirable.

Vision Outcomes and Major Complications after Endovascular Coil Embolization of Ophthalmic Segment Aneurysms

BACKGROUND AND PURPOSE: As aneurysms arising from the ophthalmic segment of the internal carotid artery increase in size, they can compress the optic nerve, prompting patients to present with visual disturbances. The purpose of this article is to describe the clinical and angiographic results with an emphasis on visual outcomes following the endovascular treatment of ophthalmic segment ICA aneurysms. MATERIALS AND METHODS: The records of 1254 patients who presented for endovascular treatment of a cerebral aneurysm were retrospectively reviewed to identify 65 consecutive patients who underwent coil embolization of an ophthalmic segment ICA aneurysm. The clinical records, treatment reports, and imaging were reviewed with a focus on visual outcomes. RESULTS: Twenty-two of the 65 patients (34%) who presented for treatment of an ophthalmic aneurysm reported a visual disturbance at presentation. Fifteen of the 22 patients (68%) experienced an improvement in their symptoms after treatment. Overall, patients with visual symptoms were significantly more likely to benefit from treatment than to have a decline in vision (P = .03). The overall morbidity was 4%, and mortality was 0%. The retreatment rate was high at 30%, though this was disproportionately weighted by an 86% retreatment rate in patients with ruptured aneurysms. CONCLUSIONS: Patients with visual symptoms attributable to ophthalmic segment ICA aneurysms undergoing endovascular coil embolization were statistically more likely to experience an improvement in their vision than to have worsening or unchanged vision. Coiling was associated with a low morbidity rate, though an elevated retreatment rate.

Stenting of symptomatic intracranial stenosis using balloon mounted coronary stents: a single center experience

Objective Intracranial atherosclerotic disease is the cause of up to 10% of ischemic strokes and transient ischemic attacks. Intracranial stenting with off-label balloon mounted coronary stents (BMCS) may be a viable alternative for patients with symptomatic intracranial stenosis who fail best medical therapy. Design Between December 2005 and June 2012, 42 symptomatic intracranial stenoses were treated with a BMCS after failing medical management. Procedural records, clinical outcomes, and imaging follow-up were reviewed. Outcome measurements included technical success rate, morbidity and mortality, long term stent patency, and clinical outcomes, as measured by the modified Rankin Scale. Results The technical success rate was 98% (41 of 42 lesions). Morbidity within the first 30u2005days was 7.1% (three of 42 lesions). Overall morbidity, including both periprocedural and long term evaluation, was 9.5% (four of 42 lesions). There were no deaths. Follow-up imaging was available for 30 stents (71%) with an average follow-up time of 35.1u2005months. Restenosis (>50%) and retreatment were observed in 20% and 10% of cases, respectively. Clinical evaluation by a neurologist ≥30u2005days postprocedure was available in 40 of 42 cases (95%) with an average of 32.1u2005months. At presentation, 55% of patients had a modified Rankin Scale (mRS) score of ≤2. At follow-up, 74% of patients were found to have an mRS score of ≤2. Conclusions This study suggests that BMCS may benefit patients with symptomatic intracranial stenosis who experience stroke or transient ischemic attack in spite of best medical therapy.

Performance and training standards for endovascular ischemic stroke treatment.

OBJECTnGamma Knife surgery (GKS) is gaining popularity in the treatment of patients with acromegaly after transsphenoidal tumor excision. In this paper, the authors examine the efficacy of GKS and predictors for biochemical remission.nnnMETHODSnThe authors retrospectively reviewed data spanning the period 1997–2008 in their hospital Gamma Knife statistics database. Forty patients with a mean age of 64 years (range 19–73 years) underwent GKS for acromegaly during that period. Transsphenoidal subtotal tumor excision had been performed prior to GKS in all these patients, except for 3 deemed to be at high surgical risk. All GKS treatment plans were formulated by the same team that performed the microsurgical procedures. Biochemical remission was defined as a growth hormone (GH) level <2 ng/ml and an insulin-like growth factor–I level that was considered normal with reference to the patients age and sex. The mean follow-up period after radiosurgery was 73.8 months (range 12–132 months).nnnRESULTSnThree patients died during the study period of causes unrelated to surgery or GKS. Twenty-nine patients (72.5%) underwent 1 radiosurgery session, and 11 patients (27.5%) required 2 radiosurgery sessions. Among the patients who underwent 1 radiosurgery session, excellent responses (76%–100% reductions in tumor size, GH level, and insulin-like growth factor–I level) were observed in 18 (62%; p < 0.0001), 20 (69%; p < 0.0001), and 5 patients (17%; p = 0.21), respectively. Tumors < 1 cm³ and those with no evidence of cavernous sinus extension were statistically significantly related to a good response in tumor size reduction (p = 0.029 and p = 0.0016, respectively). Subgroup analyses were performed in patients who attained biochemical remission in GH levels; the subgroups included patient sex, patient age, target volume, isodose volume, prescribed dose and isodose, pre-GKS GH level, and evidence of cavernous sinus extension. Only male sex was found to be a statistically significant predictor of good hormone regulation (p = 0.0124). The presence of a cavernous sinus extension was the statistically significant predictor of poor hormone control (p = 0.0011) in our study.nnnCONCLUSIONSnSubtotal tumor excision followed by GKS was an effective treatment for acromegaly. Tumors < 1 cm³ and those with no evidence of cavernous sinus extension responded well to treatment. Male sex and absence of cavernous sinus involvement can be regarded as predictors of biochemical remission. (DOI: 10.3171/2010.7.GKS10

Persistent trigeminal artery: in situ thrombosis and associated perforating vessel infarction.

We report a patient with progressive brainstem infarction despite medical therapy. The patient was transferred to our institution for potential angioplasty of basilar stenosis. Imaging review demonstrated persistent trigeminal artery in situ thrombosis and associated perforating vessel infarction. Persistent trigeminal arteries are commonly associated with an atretic basilar artery and interventional treatment can result in significant morbidity and mortality.

Posterior circulation perforator aneurysms: a proposed management algorithm

Introduction Subarachnoid hemorrhage (SAH) from posterior circulation perforator aneurysms (PCPAs) is rare and its natural history is unknown. Diagnosis may be difficult, acute management is poorly defined, and long-term recurrent SAH rates and clinical outcome data are lacking. Methods We searched our institutions records for cases of PCPA rupture and analyzed patient demographics, Hunt and Hess (HH) grades, diagnostic imaging, management, and clinical outcomes. We conducted telephone interviews to calculate modified Rankin Scale (mRS) scores. Results We identified 9 patients (6 male, 3 female) with a ruptured PCPA who presented to the University of Virginia Health System (Charlottesville, VA, USA) between 2010 and 2016. Median and mean ages were 62 and 63u2005years, respectively. Median HH grade was 3. Seven of nine (78%) PCPAs were angiographically occult on initial imaging and median time to diagnosis was 5u2005days. Three conservatively managed patients had a mean mRS score of 0.67 (range 0–1) at mean follow-up of 35.3u2005months. Antifibrinolytic therapy was administered to all conservatively managed patients without thrombotic complication. Six patients receiving endovascular treatment had a mean mRS score of 2.67 (range 0–6) at mean follow-up of 49.2u2005months. No cases of recurrent SAH were seen in the study. Conclusions The rarity of PCPA has precluded long-term clinical follow-up until now. Our experience suggests low recurrent SAH rates. Until further studies are performed, conservative management, possibly combined with antifibrinolytic therapy, may be a viable treatment with acceptable long-term outcome.