Shady Jahshan

Results of stent-assisted vs non-stent-assisted endovascular therapies in 489 cerebral aneurysms: single-center experience.

BACKGROUND Whether the addition of stenting to intracranial aneurysm coil embolization results in benefit in terms of occlusion rates or additional risk in terms of periprocedural adverse events is not clear. OBJECTIVE To report retrospectively analyzed results of endovascular aneurysm treatment comparing stent-assisted coiling with coiling without stents at our hospital from 2005 to 2009. METHODS In this retrospectively reviewed case series, aneurysms were grouped as intent-to-treat or initially treated with stent-assisted coiling (A) vs coiling alone (B) or as-treated-those that ultimately received a stent (C) or not (D). Complication and occlusion rates were compared between groups. Some patients crossed from group B to C after receiving stent placement at a later treatment following the initial therapeutic modality (without a stent). RESULTS In 459 patients, 489 aneurysms were treated by group as follows: A = 181, B = 308, C = 225, and D = 264. In stent groups (A and C), there were significantly lower frequencies of ruptured aneurysms (A vs B = 11% vs 62%, P < .001; C vs D = 20.4% vs 62.5%, P < .001) and more giant aneurysms (A vs B = 7.3% vs 1.0%, P = .001; C vs D = 5.9% vs 1.1%, P < .001). There was no statistically significant difference in permanent event-related morbidity (A vs B = 4.4% vs 4.2%, P = 1.0; C vs D = 4.4% vs 4.2%, P = 1.0). Average angiographic follow-up after last treatment was 18.2 ± 15 months (median = 14). Higher rates of complete occlusion at last angiographic follow-up were observed in stented aneurysms (A vs B = 64.6% vs 49.7%, P = .001; C vs D = 62.7% vs 48.9%, P = .003). CONCLUSION Stent-assisted aneurysm treatment resulted in higher total occlusion rates than non-stent-assisted treatment, with acceptable, comparable periprocedural event rates.

Is Bridging with Intravenous Thrombolysis of Any Benefit in Endovascular Therapy for Acute Ischemic Stroke

OBJECTIVE Large vessel occlusions with heavy clot burden are less likely to improve with intravenous (IV) thrombolysis alone. The purpose of this study was to show whether a combination of IV thrombolysis and endovascular therapy was superior to endovascular treatment alone. METHODS Data for 104 patients with acute large artery occlusion treated between 2005 and 2010 were reviewed. Forty-two received endovascular therapy in combination with IV thrombolysis (bridging group), and 62 received endovascular therapy only. Clinical outcome, mortality rate, and symptomatic intracranial hemorrhage (sICH) rate were compared between the two groups. RESULTS The two groups had similar demographic and vascular risk factor distribution, as well as National Institutes of Health Stroke Scale score on admission (mean±SD: 14.8±4.7 and 16.0±5.3; P=0.23). No difference was found in Thrombolysis in Myocardial Infarction recanalization rates (score of 2 or 3) after combined or endovascular therapy alone (83.33% and 79.03%; P=0.585). Favorable outcome, defined as a modified Rankin Scale score of <2 at 90 days, also did not differ between the bridging group and the endovascular-only group (37.5% and 32.76%; P=0.643). There was no difference in mortality rate (19.04% and 29.03%; P=0.5618) and sICH rate (11.9% and 9.68%; P=0.734). A significant difference was found in mean time from symptom onset to treatment in the bridging group and the endovascular-only group (227±88 min vs. 125±40 min; P<0.0001). CONCLUSION Combining IV thrombolysis with endovascular therapy resulted in similar outcome, revascularization, sICH, and mortality rates compared with endovascular therapy alone. Prospective clinical studies comparing both treatment strategies in acute ischemic stroke are warranted.

Stent-assisted coiling of paraclinoid aneurysms: risks and effectiveness

Background Stent assistance for treatment of wide-based aneurysms is becoming rapidly accepted. Methods Cases of aneurysms arising in the paraclinoid location of the internal carotid artery treated with intracranial stents and/or bare platinum coils were analyzed retrospectively from our prospectively collected database. We identified 70 aneurysms treated with stent assistance (including one stenting-alone case) and 24 aneurysms treated with coiling alone. Stenting-assisted coiling was achieved either as a one-time treatment or as a two-step maneuver with the stent placed several weeks before coiling, or stent-assisted coiling was used as a second maneuver in aneurysms that recanalized after previous coiling. Results In aneurysms treated with stent assistance, 60% had ≥95% occlusion at treatment completion, a result comparing favorably with the 54.2% rate of ≥95% occlusion associated with coiling alone. At last follow-up, 60 aneurysms treated with stent assistance had a 66.7% incidence of ≥95% occlusion, with no in-stent stenosis; 75% of patients treated with coiling alone had ≥95% aneurysm occlusion. Thrombus occurred during stent deployment in two patients, one with and one without neurologic sequelae; stent displacement occurred in one patient without neurologic sequelae. At last follow-up, 57 of 62 patients (91.9%) treated with stent-assisted coiling experienced excellent/good outcomes (modified Rankin scale score ≤2). These results compared favorably with those for the coiling-alone group in which 23 of 24 (95.8%) had good outcomes. Conclusion Stent-assisted coiling of paraclinoid aneurysms did not add significantly to morbidity; overall effectiveness was comparable to that of bare coiling of paraclinoid aneurysms. These results require confirmation by a prospective controlled trial.

Tandem symptomatic internal carotid artery and persistent hypoglossal artery stenosis treated by endovascular stenting and flow reversal

Persistence of the hypoglossal artery into adulthood is a rare vascular anomaly and, when present, provides the predominant vascular supply to the posterior circulation. We describe a case of vertebrobasilar insufficiency associated with severe high-grade stenosis of the persistent hypoglossal artery and tandem stenosis of the proximal ipsilateral internal carotid artery, treated by an endovascular approach. The unique anatomical and technical challenges associated with this case are reviewed in detail.

If You Want to Learn New Things, Read Old Books: Cutdown Techniques Are Well Described in the Old Literature

A t r e p t p o t p i h d d r I n 1927, the Portuguese neurologist Egas Moniz and his co-worker Almeida Lima performed the first successful cerebral angiogram (7). This was performed in a 20-year-old atient with a pineal tumor. The procedure was done by surgical xposure of the carotid artery. Initially, most clinicians favored urgical exposure of the carotid artery rather than percutaneous njection. Later, the percutaneous approach became the standard oute for angiographic injection as a part of the diagnostic maging work-up for intracranial lesions, until the introduction of omputed tomography in the 1970s.

External carotid dissection and external carotid proatlantal intersegmental artery with subclavian steal prompting external carotid and subclavian artery stenting.

The authors describe a case of a proatlantal intersegmental artery seen in the setting of external carotid artery dissection and subclavian steal due to proximal subclavian artery stenosis.

Occlusive concomitant dissections of the carotid and coronary arteries treated with stent placement

Spontaneous coronary artery dissection is rare and previously was associated with a high mortality rate. Spontaneous dissection of the internal carotid artery is a cause of ischemic stroke, especially in young patients. Medical therapy allows healing of the carotid dissection in most patients, although endovascular stent placement has been reported for the treatment of selected cases. A case is reported of a patient in their late 30s who presented with a symptomatic occlusive cervical carotid artery dissection and, 7 days later, developed an acute coronary syndrome due to an occlusive dissection of the intermediate artery. Both lesions were treated with stent placement.

Endovascular Intracranial Aneurysm Treatment

With superior operative morbidity, similar rupture outcomes after treatment, and patient preference for minimally invasive operative techniques, endovascular treatment of intracranial aneurysms is performed with increasing frequency as compared to microsurgical techniques, including clip ligation. Endovascular treatment of intracranial aneurysms requires facility with a multitude of interventional techniques. The constantly expanding list of endovascular tools available currently includes detachable coils, stents, balloons, high-density embolic glues, and flow-diversion devices.

Embolic Intracranial Strokes: Catheter-Directed Thrombolysis

In the setting of acute ischemic stroke, an intra-arterial (IA) pharmacological approach allows catheter-directed delivery of thrombolytic agents to the clot, offering several potential advantages by comparison with systemic (intravenous, IV) thrombolysis. First, a smaller dose of thrombolytic agent is utilized, thereby minimizing systemic hemorrhagic side effects; at the same time, a high concentration of the agent is locally delivered to the occlusion site. Second, using direct fluoroscopic guidance, a microcatheter can be placed immediately next to or directly into the thrombus. Third, both continuous and bolus delivery of thrombolytics can be given, based on specific features of the clot and the degree of response to lysis, which can be directly visualized during a microcatheter angiogram. IA thrombolysis can be used for thrombi located within smaller vessels, such as distal M2 or M3 branches of the middle cerebral artery (MCA), which often cannot be reached with mechanical thrombectomy devices. The angiographic appearance of a normal intracranial arterial anatomy is shown in Fig. 2.1.

E-022 Tandem symptomatic internal carotid artery and persistent hypoglossal artery stenosis treated by endovascular stenting and flow reversal: case report

The persistence of the hypoglossal artery (PHA) into adulthood is a very rare vascular anomaly and, when present, provides the only vascular supply to the posterior circulation. We describe a case of a 64-year-old male presenting with symptoms of vertebro-basilar insufficiency associated with severe high grade stenosis of a persistent hypoglossal artery and tandem stenosis of the proximal ipsilateral internal carotid artery (ICA), both treated by an endovascular approach. Given this patients comorbidities and the potential anatomic difficulties presented by the PHA during performance of a carotid endarterectomy, we decided to proceed with stent placement in both the proximal ICA and the PHA in the same treatment setting. The high degree of stenosis in the PHA and the presence of a large atherosclerotic plaque in the proximal ICA were felt to be good indications for proximal embolic protection by a flow-reversal technique using the GORE Flow Reversal System (W.L.Gore and Associates, Inc., Flagstaff, AZ). The unique anatomical and technical challenges associated with this case are reviewed in detail. Post-operatively, the patient improved clinically, remaining with minimal subjective right sided numbness and he was discharged home on ASA, Effient and Crestor. The patient had no complications related to the endovascular procedure. Competing interests J Eller: None. S Jahshan: None. T Dumont: None. P Kan: None. E Levy: Stent Assisted Recanalization in Acute Ischemic Stroke—SARIS, Boston Scientific, Codman & Shurtleff, ev3/Covidien Vascular Therapies. Scientific Advisors to Codman and Shurtleff, ev3/Covidien Vascular Therapies, TheraSyn Sensors Inc., Intratech Medical Ltd., Mynx/Access Closure. Fees for carotid stenting training from Abbott Vascular, Fees for carotid stenting training from ev3/Covidien Vascular Therapies. A Siddiqui: National Institutes of Health (co-investigator NINDS 1RO1NS064592-01A1 Hemodynamic Induction of pathologic remodeling leading to intracranial aneurysms, Research Development Award from University at Buffalo. Codman & Shurtleff, Inc, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra. Genentech. Abbott Vascular, American Association of Neurological Surgeons courses.Abstract E-022 Figure 1