Pedro Vega

New Pipeline Flex device: initial experience and technical nuances

Background Flow diverter stents (FDS) have been described as a breakthrough in the treatment of intracranial aneurysms. Of the various flow diverter models, the Pipeline device has been the main approved and used device, with established and good long-term results. Objective To present the first series of patients treated with its new version, the Pipeline Flex device. This has kept the same device design and configuration but redesigned and completely modified the delivery system. Methods In this technical report, we include 10 consecutive patients harboring 12 saccular aneurysms of the anterior circulation. We report the main changes on the system, immediate results, and technical nuances with illustrative cases. Results We implanted 12 devices, including 11 Pipeline Flex and one Pipeline device. We used the old version in one case that required a second layer with a short length not available in the Pipeline Flex size range. All attempts at treatment were successful and no device was discharged or removed. Recovery was required or used in half of the cases with good or excellent performance, except in one case that presented with multiple proximal loops and tight curves. We had two transitory events without ischemic lesions on MRI that recovered 1 and 4 h after all patients were discharged home asymptomatic. Conclusions Pipeline Flex represents a major advance in FDS technology. The redesigned system has significantly improved the deployment of the Pipeline stent, by enabling the operator to resheath the device. It has the potential to continue revolutionizing the endovascular approach for intracranial aneurysms.

Balloon-assisted extrasaccular coil embolization technique for the treatment of very small cerebral aneurysms.

Treatment of very small ruptured cerebral aneurysms (< 2 mm) continues to present a challenge. These lesions are difficult to treat both with neurosurgical and endovascular techniques. A neurosurgical approach is still the treatment of choice for these lesions at many centers because of high rupture rates related to endovascular treatment; however, there are clinical circumstances in which the neurosurgical option cannot be offered. In their review of the literature, the authors did not find any series reporting endovascular treatment of these very small aneurysms. In the present study, the authors report their experience with the endovascular treatment of a series of 4 ruptured aneurysms smaller than 2 mm from neck to dome. They describe their technique of using a remodelling balloon to stabilize the tip of the microcatheter in the neck of the aneurysm without entering it at any time, and of inserting the coil from outside the sac to minimize the risk of intraoperative rupture, which is very high when conventional endovascular embolization is performed.

Diagnóstico de muerte encefálica mediante tomografia computarizada multicorte : angio-TC y perfusión cérébral

BD was diagnosed by clinical examination, electroencephalogram (EEG), Transcranial Doppler (TCD) and multislice CT of 64 detectors. Initially, a brain perfusion study was performed. This was followed by supra-aortic trunk and brain artery angiography with acquisition of images using 0.5 mm slices, from the origin of the aortic root to the vertex. In all the patients, BD diagnosis was verified by clinical examination, EEG and TCD. Brain perfusion never detected brain blood flow. The angioCT through internal carotid arteries and vertebral arteries demonstrated complete absence of intracranial circulation, observing circulation of the external carotid artery branches. Sensitivity and specificity of the method compared with clinical examination was 100%. These findings demonstrate that the study of brain perfusion and brain angiography by multislice CT scan is a rapid and minimally invasive technique, that is easily available and that shows the absence of brain blood flow through the four vascular trunks. This technique makes it possible to made the diagnosis of BD with high diagnostic safety. Its use has special interest in patients with clinical diagnostic difficulty due to treatment with sedative drugs and serious metabolic alterations.BD was diagnosed by clinical examination, electroencephalogram (EEG), Transcranial Doppler (TCD) and multislice CT of 64 detectors. Initially, a brain perfusion study was performed. This was followed by supra-aortic trunk and brain artery angiography with acquisition of images using 0.5 mm slices, from the origin of the aortic root to the vertex. In all the patients, BD diagnosis was verified by clinical examination, EEG and TCD. Brain perfusion never detected brain blood flow. The angioCT through internal carotid arteries and vertebral arteries demonstrated complete absence of intracranial circulation, observing circulation of the external carotid artery branches. Sensitivity and specificity of the method compared with clinical examination was 100%. These findings demonstrate that the study of brain perfusion and brain angiography by multislice CT scan is a rapid and minimally invasive technique, that is easily available and that shows the absence of brain blood flow through the four vascular trunks. This technique makes it possible to made the diagnosis of BD with high diagnostic safety. Its use has special interest in patients with clinical diagnostic difficulty due to treatment with sedative drugs and serious metabolic alterations.

Intracranial stent placement in a patient with moyamoya disease

Moyamoya disease is a rare cerebrovascular condition characterized by progressive occlusion of the major branches of intracerebral arteries. Angiographic findings include bilateral stenotic lesions at the distal portion of the internal carotid artery or middle and anterior cerebral arteries. The result of these stenoses is a severe impairment of the cerebrovascular reserve capacity. This process is accompanied by the development of an extensive collateral network of pathological vessels at the cerebral base with ‘‘puff of smoke’’ appearance. No known treatment can reverse the primary disease process. Current treatments are designed to prevent strokes by improving blood flow to the affected cerebral hemisphere [1]. Increasingly, surgical revascularization is gaining acceptance as the primary treatment for Moyamoya, given the contrast between poor response to medical therapy and the documented success of surgery [2]. A 34-year-old right-handed female presented at the emergency department complaining of transient dysarthria and sensitive symptoms on the four limbs. During her hospitalization she suffered a sudden episode of aphasia and severe paresis of her right arm. Cranial MRI showed several lesions in both frontal and parietal lobes with restricted diffusion, suggestive of subacute ischemic lesions. The lesions were located in the deep borderzones, implying a hemodynamic origin (Fig. 1). A conventional angiography was consequently performed demonstrating narrowing of the distal portion of both internal carotid arteries consistent with Moyamoya disease. Middle and anterior cerebral arteries of both hemispheres were also affected, with compensation through leptomeningeal and posterior circulation. There were also fine basal collaterals, at least on the right side. Given these findings, the patient was transferred to the Intermediate Care Unit. The next days her neurological status did not improve, while her blood pressure remained around 100/60 mmHg. Echocardiography, tests for acute myocardial infarction, and ECG monitoring were normal. In this situation, the revascularization seemed to be priority. An angioplasty with placement of a Wingspan 2.5 9 20 mm stent (Boston Scientific) in the left middle artery was performed without any complication. The patient’s clinical condition improved quickly. The next day she patient was able to answer simple questions, at day 15 she had limited spontaneous speech, and 1 month later, only little fluency difficulties remained, while the right arm paresis had recovered persisting weakness of the hand. CT with angiographic sequences at the moment of the discharge showed permeability of the stent with recovery of flow in the left middle cerebral artery and disappearance of the collateral compensation. Thirteen months after the angioplasty, another arteriography was performed showing minimal narrowing of the stent without repercussion of the lumen. She has suffered two partial seizures but no new ischemic events. Her current treatment includes double antiaggregation and Levetiracetam. Surgical direct and indirect revascularization techniques are the preferred treatment for moyamoya disease and can ameliorate the progression of this condition, but are associated with significant morbidity and mortality. D. Santirso (&) P. Oliva M. Gonzalez E. Murias P. Vega A. Gil S. Calleja Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Spain e-mail: carpintirso@gmail.com

Tratamiento endovascular y trombólisis intraarterial en el ictus isquémico agudo

OBJECTIVE Analysis of the safety and efficacy of intra-arterial thrombolysis therapy and endovascular treatment in acute ischemic stroke. DESIGN AND AREA: An observational prospective study in the Intensive Care Unit. PATIENTS AND METHODS 16 patients had endovascular treatment. Epidemiological data, arterial occlusion site, time between stroke onset and treatment, treatment indication, NIHSS scale at admission and discharge from hospital, complications and functional outcome measured by modified Rankin scale (obtained by telephone survey) were collected. RESULTS Ten male patients with a mean age of 59 years (29-74) were included. The mean stay in the ICU was 6 days (1-33). Seven patients required mechanical ventilation. Treatment indications were: intravenous thrombolysis failure in 4 patients, major vessel occlusion in 5, outside of the therapeutic window in 2, posterior circulation occlusion in 3, outside of the therapeutic window plus major vessel occlusion in 1 and intravenous thrombolysis contraindication in 1. The occlusion site was on posterior circulation in 3 and on carotid territories and branches in 13. Thrombolytic treatment used was Urokinase at a dose of 100,000-600,000IU. Four patients required mechanical embolectomy and 10 stent implantation. Complete recanalization was observed in 11 (69%) and partial in 4 (25%). Three evolved to brain death. Six patients (46%) had a favorable outcome (modified Rankin scale score ≤ 2). Technical complication was 1 femoral artery pseudoaneurysm. CONCLUSIONS With the intra-arterial treatment, high rates of recanalization and favorable outcome are obtained with few complications. It could be indicated in patients with severe neurological injury (NIHSS ≥ 10), evolution time between 3-6h, intravenous thrombolysis contraindication and proximal arterial occlusion.

Floating Thrombus as a Marker of Unstable Atheromatous Carotid Plaque

Floating thrombus in a carotid artery is an uncommon pathology with a high risk of embolism. We present three patients diagnosed with acute stroke, with a floating thrombus complicating an atheromatous plaque, who were treated with anticoagulants and statins. Although two patients had satisfactory results, one patient suffered a stroke related to plaque progression nearly 3 years after initial presentation. Medical treatment seems to be a good initial option, although late cerebral ischemic complications may be seen due to carotid plaque instability. Delayed carotid endarterectomy or stenting should be considered in cases with subsequent plaque progression.

OriginalTratamiento endovascular y trombólisis intraarterial en el ictus isquémico agudoEndovascular treatment and intra-arterial thrombolysis in acute ischemic stroke

OBJECTIVE Analysis of the safety and efficacy of intra-arterial thrombolysis therapy and endovascular treatment in acute ischemic stroke. DESIGN AND AREA: An observational prospective study in the Intensive Care Unit. PATIENTS AND METHODS 16 patients had endovascular treatment. Epidemiological data, arterial occlusion site, time between stroke onset and treatment, treatment indication, NIHSS scale at admission and discharge from hospital, complications and functional outcome measured by modified Rankin scale (obtained by telephone survey) were collected. RESULTS Ten male patients with a mean age of 59 years (29-74) were included. The mean stay in the ICU was 6 days (1-33). Seven patients required mechanical ventilation. Treatment indications were: intravenous thrombolysis failure in 4 patients, major vessel occlusion in 5, outside of the therapeutic window in 2, posterior circulation occlusion in 3, outside of the therapeutic window plus major vessel occlusion in 1 and intravenous thrombolysis contraindication in 1. The occlusion site was on posterior circulation in 3 and on carotid territories and branches in 13. Thrombolytic treatment used was Urokinase at a dose of 100,000-600,000IU. Four patients required mechanical embolectomy and 10 stent implantation. Complete recanalization was observed in 11 (69%) and partial in 4 (25%). Three evolved to brain death. Six patients (46%) had a favorable outcome (modified Rankin scale score ≤ 2). Technical complication was 1 femoral artery pseudoaneurysm. CONCLUSIONS With the intra-arterial treatment, high rates of recanalization and favorable outcome are obtained with few complications. It could be indicated in patients with severe neurological injury (NIHSS ≥ 10), evolution time between 3-6h, intravenous thrombolysis contraindication and proximal arterial occlusion.

Late spontaneous recanalization of symptomatic atheromatous internal carotid artery occlusion

Introduction Definitive treatment of symptomatic atheromatous internal carotid artery occlusion remains controversial, as far as in rare cases, late spontaneous recanalization has been seen. Methods We consecutively studied 182 patients (January 2003 to August 2012) with an ischemic stroke in the internal carotid artery territory and diagnosis of atheromatous internal carotid artery occlusion during hospitalization. Findings Seven patients presented a late spontaneous recanalization (>3 months) of the internal carotid artery. We described therapeutic attitude according to usual care in these patients. Conclusions The authors attempt to highlight the unusual condition of recanalization after a symptomatic atheromatous chronic internal carotid artery occlusion. If these patients can be treated similar to patients with asymptomatic carotid pathology, then this needs to be clarified. However, due to the risk of ipsi- and contralateral ischemic strokes, revascularization techniques should be considered in certain cases. More studies are needed to establish the most appropriate therapeutical approach in order to avoid arbitrary treatment of these patients.

Endovascular treatment in the acute and non-acute phases of carotid dissection: a therapeutic approach

Background Carotid dissection (CD) may, in certain cases, lead to significant stenosis, occlusion, or pseudoaneurysm formation, causing embolic stroke or hemodynamic failure, despite medical therapy. Objective To evaluate the results of endovascular treatment and clinical outcomes of patients with CD. Methods A four-hospital retrospective study of endovascular treatment of extracranial CD in which medical treatment had failed or patients presented with a National Institute of Health Stroke Scale (NIHSS) score ≥8. Results Thirty-eight patients (mean age 46.6±13.5 years, 78.9% male, 84.2% spontaneous CD, 44.7% left CD and 26.3% bilateral CD) were analyzed. In 24 patients (63.2%) treatment was undertaken in the acute-phase CD (APCD). IV recombinant tissue plasminogen activator was administered in 7 (29.2%) APCD cases. The patients with APCD exhibited a high rate of successful revascularization (Thrombolysis In Cerebral Infarction ≥2b; 19 patients (79.2%)), a low risk of symptomatic intracranial hemorrhage (n=2 (8.3%)), and good global functional outcomes (modified Rankin Scale (mRS) ≤2; n=17 (70.8%)). Good recanalization correlated (p=0.001) with good clinical evolution (mRS ≤2) in the patients with APCD. Of the 14 patients with non-acute phase CD (NAPCD), seven were treated for pseudoaneurysm with multiple stents (six patients) or covered prostheses, with stenosis being treated in the remaining seven patients. Conclusions Endovascular treatment of selected cases of patients with CD associated with thromboembolic events and hemodynamic failure after unsuccessful medical therapy is a safe and effective method of restoring vessel lumen integrity, with good short-term clinical evolution.

Manejo de las epistaxis graves y/o refractarias

OBJECTIVE The objective was to determine the results of the treatment of severe and/or refractory epistaxis requiring hospital admission. In addition, the results of arterial ligation versus embolization were compared. MATERIAL AND METHOD Sixty-three patients with severe and/or refractory epistaxis requiring hospital admission between August 2014 and December 2016 were included prospectively. RESULTS Eleven patients (17%) underwent embolization, 5 (8%) endoscopy ligation and the remaining 47 (75%) underwent conservative treatment with tamponade. The mean age of the patients in which conservative measures were sufficient was 72 years, while the age of those treated with embolization was 71 years and of those who underwent surgery was 53 years. For the patients who underwent conservative treatment or surgery, the average stay was 6 days, compared to 9 days for those who underwent embolization. One patient suffered a hemispheric stroke after embolization. No post-surgical complications were observed. CONCLUSIONS Most cases of severe and/or refractory epistaxis are resolved by conventional tamponade. Endoscopy ligation is associated with a decrease in hospital stay, without serious complications. It is advisable to have all the possible therapeutic options available, for which the presence of interventional radiologists and experienced surgeons is essential to avoid complications and decide the treatment to be performed individually for each patient.