Mohamed S. Teleb

Stenting and Angioplasty for Idiopathic Intracranial Hypertension: A Case Series with Clinical, Angiographic, Ophthalmological, Complication, and Pressure Reporting

Previous studies have demonstrated that cerebral dural sinus stenosis (DSS) may be a potential patho‐physiological cause of idiopathic intracranial hypertension (IIH). Endovascular therapy for DSS is emerging as a potential alternative to treat IIH. Here, we present the results of our case series.

Safety and feasibility of simultaneous ipsilateral proximal carotid artery stenting and cerebral aneurysm coiling

Coexistence of cerebral aneurysm and carotid artery disease may be encountered in clinical practice. Theoretical increase in aneurysmal blood flow may increase risk of rupture if carotid artery disease is treated first. If aneurysm coiling is performed first, stroke risk may increase while repeatedly crossing the diseased artery. It is controversial which disease to treat first, and whether it is safe to treat both simultaneously via endovascular procedures. We document the safety and feasibility of such an approach. Review of collected neurointerventional database at our institution was performed for patients who underwent both carotid artery stenting (CAS) and aneurysm coil embolization (ACE) simultaneously. All patients underwent carotid stenting followed by aneurysm coiling in the same setting. Demographic, clinical data, and outcome measures including success rate and periprocedural complications were collected. Five hundred and ninety aneurysms coiling were screened for patients who underwent combined CAS and ACE. Ten patients were identified. Mean age was 67.7 years (range 51–89). The success rate for stenting and coiling was 100% with no immediate complications. The coiling procedure time was extended by an average of 45 min for performing both procedures jointly. No stroke, TIAs, or aneurysmal rebleeding was found on their most recent follow up. Our case series demonstrates that it is safe and feasible to perform CAS and ACE simultaneously as one procedure which may avoid unwanted risk of treating either disease at two separate time sessions.

Endovascular reconstruction for progressively worsening carotid artery dissection

Background Carotid artery dissection is an important cause of stroke in young patients. Selection criteria for endovascular repair have not been well defined and limited data exist on long-term outcomes of stent reconstruction. Objective To report the immediate and long-term clinical and radiographic outcomes of patients treated with stent placement for progressively worsening symptomatic carotid arterial dissection despite antithrombotic therapy. Methods A single institution neuro-endovascular database was accessed to identify consecutive cases in which carotid artery dissection was treated with endovascular repair between 2006 and 2012. Clinical, demographic, radiographic, and procedural data were obtained through chart review. Results A total of 22 patients were identified and included 27 carotid artery dissection repairs with stent implantation. The mean age was 43 years (±8.7) with 13 patients being women. Traumatic dissections were seen in 9 (40.9%) patients and spontaneous dissections in 13 (59.1%) patients. All patients were symptomatic and were started on antithrombotic therapy on diagnosis. Most common indications for treatment included recurrent ischemia despite antithrombotic therapy in 15 (55.5%) arteries and enlarging dissecting aneurysm in 4 (14.8%) arteries. Mean degree of stenosis was 79.1%. Mean number of stents used was 1.88 (range 1–4). There was 1 (4.5%) asymptomatic peri-procedural thromboembolic event. Median clinical follow-up was 14 months (range 3–40) and median imaging follow-up was 14 months (range 3–38). There was 1 (4.5%) case of recurrent transient ischemic attack. There was no death, significant restenosis or stroke in the territory of the treated vessel during the duration of the follow-up. Conclusions Endovascular stent reconstruction for the treatment of selected patients with progressively worsening carotid dissection despite medical management is feasible with acceptable immediate and long-term clinical and radiographic outcomes. To be able to draw more robust conclusions, further evaluation with larger number of patients and longer follow-up is needed.

Safety and predictors of aneurysm retreatment for remnant intracranial aneurysm after initial endovascular embolization

Introduction Aneurysmal subarachnoid hemorrhage (SAH) is a rare but devastating form of stroke. Endovascular therapy has been criticized for its higher rate of recanalization and retreatment. The safety and predictors of retreatment are unknown. We report the clinical outcomes, imaging outcomes and predictors for aneurysm retreatment after initial endovascular embolization. Method We identified patients who underwent endovascular retreatment from July 2005 through November 2011. Aneurysm and patient data were collected. Periprocedural complications were reported as intraoperative perforation (IOP) or thromboembolic event (TEE). Aneurysm and patient characteristics were compared between aneurysms requiring retreatment and those not requiring retreatment to evaluate aneurysm retreatment predictors. Results A total of 111/871 (13%) aneurysms underwent retreatment. Two (0.2%) were retreated for recurrent acute SAH, 82 (74%) aneurysms were located in the anterior circulation, 47 (42%) required stent and 5 (5%) required balloon assist during retreatment. There were a total of 5 (5%) IOP and 6 (5%) TEE from which 2 (2%) and 1 (1%) were symptomatic, respectively. Overall symptomatic events rate were 2.7%. Patients were followed up for an average of 15±14 months. Seven (0.8%) aneurysms required a second retreatment without any recurrent SAH. Multivariable analysis revealed an OR for aneurysms requiring retreatment of 2.965 for aneurysms presenting as aneurysmal SAH, 1.791 for aneurysms in the posterior circulation and 1.053 for aneurysms with large dome size. Conclusions Aneurysm retreatment is a safe option without a significant increase in morbidity or mortality. SAH, posterior circulation aneurysms and larger aneurysm dome size are predictors of aneurysms requiring retreatment.

Middle Cerebral Artery Aneurysm Endovascular and Surgical Therapies: Comprehensive Literature Review and Local Experience

The middle cerebral artery is a common location for cerebral aneurysms and is associated with a lower risk of rupture than aneurysms located in the anterior or posterior communicating arteries. No evidence supports the superiority of clipping over coiling to treat middle cerebral artery aneurysm (MCAA) or vice versa. The feasibility of treating the MCAA with endovascular therapy as the first choice of treatment in cohorts of nonselected aneurysms exceeds 90%. A randomized clinical trial comparing the 2 approaches in nonselected cases with long-term follow-up will shed light on which patients may benefit from one approach over another.

Endovascular Management of Intracranial Atherosclerosis

Intracranial atherosclerotic disease (ICAD) represents one of the most common causes of ischemic stroke worldwide, yet our understanding remains limited regarding the best treatment options for this complex disease with a high recurrence rate of stroke. Although medical therapy has proved to be effective in lowering the risk of stroke, certain high-risk ICAD patients may derive benefit from endovascular therapy. This review presents the current treatment options for the endovascular management of ICAD and highlights the recent relevant literature.

Endovascular Acute Ischemic Stroke Treatment with FlowGate Balloon Guide Catheter: A Single-Center Observational Study of FlowGate Balloon Guide Catheter Use

Background: Treatment of large vessel occlusion acute ischemic stroke with mechanical thrombectomy has become the standard of care after recent clinical trials. However, the degree of recanalization with stent retrievers remains very important in overall outcomes. We sought to review the utility of a new balloon guide catheter (BGC) in improving the degree of recanalization in conjunction with mechanical thrombectomy. Methods: The medical records of a prospectively collected endovascular ischemic stroke database were reviewed. All consecutive strokes when a FlowGate BGC was used with a thrombectomy stent retriever were identified. Use of a FlowGate BGC, number of passes, final Thrombolysis in Cerebral Infarction (TICI) score, trackability, and use of adjunct devices were all collected and analyzed. Results: Use of a FlowGate BGC resulted in 64% (33/52) first-pass effect (FPE) of TICI 2b/3, and specifically 46% (24/52) TICI 3 FPE (true FPE). A total of 52/62 (84%) of thrombectomy cases were treated with BGCs. In the remaining 10, the BGC was not inflated or used due to the clot not being visualized or the lesions being distal and BGC use thus not deemed appropriate. Adjunct use of an aspiration catheter was seen in 12% (6/52) of cases. The overall success with FlowGate BGCs with one or more passes of TICI 2b/3 was 94% (49/52). Trackability was achieved in 92% (57/62) of cases. Conclusions: Use of the FlowGate BGC as an adjunct to mechanical thrombectomy was associated with good FPE and an overall recanalization of TICI 2b/3 of 94%.

E-011 TICI Quantified: Automated Cerebral Revascularization Grading in Acute Ischemic Stroke

Introduction Cerebral angiographic revascularization grading is the primary method for measuring the angiographic success of acute ischemic stroke (AIS) endovascular therapy and is one of the strongest predictors for clinical outcome. Of the many reported scales, the modified Treatment in Cerebral Ischemia (mTICI) scale is the preferred grading scale for assessment of revascularization. Currently, mTICI grading is based on visual crude estimations by the operator, which may introduce error and bias in to the evaluation. Here, we present an update on our on-going study to automatize mTICI and provide a more accurate and precise grading tool: Quantified TICI (qTICI). Methods Phase one of the project is to develop a database of 15–30 patients with an aplastic/hypoplastic anterior cerebral artery (ACA) in order to establish the standard average and predicted 100% qTICI for the isolated middle cerebral artery (MCA) territory. To map the MCA territory, a retrospective review of patients between the ages of 18–85 was performed from our Digital Subtraction Angiography (DSA) database at the Medical College of Wisconsin. All consecutive cases with aplastic/hypoplastic ACA (to minimise contaminating blood flow from the ACA territory) are included in this study. Existing Siemens software is currently in use to estimate the territory of normal capillary blush and establish normal blood flow values in this database. Results We have identified 19 consecutive patients with aplastic/hypoplastic ACA between the ages of 18–85, from our DSA database of over 3000 cases. Nine patients had aplastic A1 and 10 had hypoplastic A1 segments of the ACA. Once normal capillary blush of the MCA territory has been established and automatized, we will use those normalised values per age to compare the capillary blush and blood flow of the pathological cases- a cohort of 20–25 patients who have stroke secondary to MCA occlusion. Values of qTICI will be compared and validated using standard visual estimation of mTICI. Clinical correlation of qTICI with outcome will also be performed. The goal is to establish software that will accurately grade mTICI on a continuous scale rather than using the current crude visual estimation with wide range 4 strata, which will eliminate the operator dependent bias and increase the precision and accuracy of the revascularization grading. Conclusion The qTICI Grading Software once developed will have the potential to revolutionise the way clinicians and interventionalists grade revascularization post AIS endovascular therapy. The clinical implications of establishing automatized and quantified revascularization scale is critical in improving treatment safety and efficacy. Disclosures A. Sattar: None. K. Asif: None. M. Teleb: None. A. Castonguay: None. M. Issa: None. O. Zaidat: None.

E-069 Validation of a New Modified Capillary Index Score Angiographic Real Time Assessment of Dead vs Salvable Tissue

Background The original capillary index score publication only included patients that had full digital subtraction angiograms (DSA) before stroke intervention. This CIS was a single center publication with no external validation. Many centers do not perform a full DSA to assess all collaterals before intervention. Hypothesis A modified capillary index score (mCIS) using only the ICA injection can predict outcome in MCA occlusions (only MCA occlusions included). Objective Validate the utility and use of a modified capillary index score (mCIS) to assess outcomes and improvement in acute stroke patients. Methods mCIS was assessed on all consecutive patients with an MCA occlusion with complete database information. NIHSS, recanalization (mTICI), and mRS before and after treatment were assessed. mCIS of 2–3 was considered favorable as per original publication. Correlation between favorable CIS, NIHSS improvement, and mRS (0–3 good) were assessed. Results 33 patients with MCA occlusion with complete data sets where assessed. 63.6% (21/33) had a favorable mCIS (2–3) and 36.4% had a poor mCIS(0–1). Recanalization of TICI 2b or greater was achieved in 42.9% (9/21) of patients with favorable mCIS and 58.3% (7/12) of patients with poor mCIS. Of those with favorable mCIS 28.6% (6/21) had a good mRS of ≤3 at discharge vs those with poor mCIS while those with a poor mCIS 33.3% had a good mRS at discharge. However, mortality was lower in favorable mCIS vs. poor mCIS (9.5 vs. 33.35, p = 0.09). Conclusions A modified CIS is did not predict the functional outcome but may be predictor of mortality. Small sample size, lack of long-term follow up, or the lower rate of recanalization of those with favorable mCIS could have contributed to the negative outcome. A prospective or larger study with long term follow up is needed for validation. References Al-Ali F, Jefferson A, Barrow T, et al. The capillary index score: rethinking the acute ischemic stroke treatment algorithm. Results from the Borgess Medical Center Acute Ischemic Stroke Registry. J Neurointerv Surg. 2013;5(2):139–143. doi:10.1136/neurintsurg-2011-010146 Capillary Index Score, Baseline Characteristics and Outcomes Favorable mCIS Unfavorable mCIS P Value Baseline NIHSS 14 + /-6.9 18.3 + /-3.9 0.051 Age 64.3 + /-16.6 68.8 + /-4.9 0.453 Good Recanalization (2b-3) 42.9% (9/21) 58.3% (7/12) 0.391 NIHSS at Discharge 10.8 + /-7.5 15 + /-2.5 0.099 NIHSS at Discharge in TICI 2b and higher 5.8 + /-4.2 13.4 + /-13.7 0.067 Mortality 2/21 (9.5%) 4/12 (33.33%) 0.093 Good Outcome (mRS < = 3) 28.6% (6/21) 33.33% (4/12) 0.775 Good Outcome in TICI2b or higher 12 mRS < = 3) 5/9 (55.6%) 4/7 (57.1%) 0.0949 Disclosures M. Teleb: None. M. Noufal: None. A. Sattar: None. W. Wazni: None. M. Issa: None. K. Asif: None. A. Gheith: None. A. Castonguay: None. O. Zaidat: 2; C; Penumbra, Stryker, Covidie. 3; C; Penumbra, Stryker, Covidien.

Angiographic Lumen Changes Associated with Oversized Intracranial Stent Implantation for Aneurysm Treatment

The effect of oversized intracranial stent implantation, and potential excessive neointimal hyperplasia from the chronic outward radial force, has not been reported. We sought to compare the angiographic narrowing associated with implantation of oversized stents.