Sonal Mehta

Hospital Mortality and Complications of Electively Clipped or Coiled Unruptured Intracranial Aneurysm

Background and Purpose— To determine the hospital mortality rates associated with elective surgical clipping and endovascular coiling of unruptured intracranial aneurysms. Methods— We identified a cohort of patients electively admitted to US hospitals with the diagnosis of unruptured intracranial aneurysm from the National Inpatient Sample database for the years 2000 through 2006. Patient demographics, hospital-associated complications, and in-hospital mortality were compared among the treatment groups. A multivariate logistic regression analysis was used to identify independent variables associated with hospital mortality. Cochrane–Armitage test was used to assess the trend of hospital use of these procedures. Results— After data cleansing, 3738 (34.3%) patients had aneurysm clipping and 3498 (32.1%) had endovascular coiling. The basic demographics including age, race, and comorbidity indices were similar between the groups. The length of hospital stay was longer in the clipped population (median 4 versus 1 day; P<0.0001), incurring a higher hospital charge in the coiled population (median

Is Thrombolysis Safe in the Elderly? Analysis of a National Database

42 070 versus

Risk of contrast-induced nephropathy in patients undergoing endovascular treatment of acute ischemic stroke

38 166; P<0.0001). Hospital mortality was higher in the clipped population: 60 (1.6%) versus 20 (0.57%; adjusted odds ratio 3.63; 95% CI, 1.57, 8.42). Perioperative intracerebral hemorrhage and acute ischemic stroke were higher in the clipped population. The rate of hospital use of the endovascular coiling has increased over the years included in this study (<0.0001). Conclusions— Elective coiling of unruptured intracranial aneurysms is associated with fewer deaths and perioperative complications compared with elective clipping. The trend of hospital use of the coiling procedures has increased during recent years.

Isolated necrotizing myopathy associated with ANTI-PL12 antibody.

Background and Purpose— Thrombolysis for acute ischemic stroke in the elderly population is seldom administered. Methods— In this study, we evaluated the risks of thrombolysis, including the mortality and intracerebral hemorrhage (ICH) rates in this population. A cohort of patients was identified from the National Inpatient Sample database for the years 2000–2006. Age was categorized in 2 groups, including those between 18 and 80 years and those >80 years. Multivariate logistic regression analysis was used to assess covariates associated with hospital mortality and ICH. A total of 524 997 patients were admitted for acute ischemic stroke; 143 093 (27.2%) were >80 years. A total of 7950 patients were treated with thrombolysis, of which 1659 (20.9%) were >80 years. Elderly patients received less frequent thrombolysis compared with the younger population (1.05% versus 1.72%). Results— In the whole cohort, the mortality rate was higher in the older population (12.80% versus 8.99%). For those treated with thrombolysis, the mortality rate and risk of ICH were higher among those >80 years (16.9% versus 11.5%; odds ratio: 1.56 [95% CI: 1.35 to 1.82] and 5.73% versus 4.40%; odds ratio: 1.31 [95% CI: 1.03 to 1.67], respectively). Multivariate logistic regression analysis showed that the presence of ICH (odds ratio: 2.24 [95% CI: 1.89 to 2.65]) was associated with higher mortality rates but not the use of thrombolysis (odds ratio: 1.14 [95% CI: 0.98 to 1.33]). Conclusions— Despite the higher mortality rate in the older population, the use of thrombolysis does not predict death; however, the use of thrombolysis was associated with high risk of ICH.

Air myelopathy following a cervical epidural injection.

Background and purpose We report the incidence and risk factors for contrast-induced nephropathy after the use of iodinated contrast for endovascular treatment of acute ischemic stroke. Methods A retrospective chart review was performed in 194 consecutive patients who underwent endovascular treatment for acute ischemic stroke between January 2006 and January 2011. No patients were excluded from treatment for elevated creatinine (Cr). Each patient received approximately 150 ml intra-arterial non-ionic low-osmolar contrast agent (Optiray 320) during the endovascular procedure. Contrast-induced nephropathy (CIN) was defined according to the Acute Kidney Injury Network criteria as a relative increase of serum Cr 50% above the baseline or an absolute increase of 0.3 mg/dl at 48 h following the endovascular procedure. Results Of 194 patients (mean age 65±14 years), 52% were women (n=100) and 25% (n=48) were diabetic. Baseline Cr levels for 191 patients ranged between 0.4 and 2.7 mg/dl. Three patients on chronic hemodialysis had baseline Cr levels ranging between 5.3 and 6.1 mg/dl. Cr was ≤1.5 mg/dl in 163 patients (84%) and ≥ 1.5 mg/dl in 31 (16%). Three of the 191 patients (1.5%) developed CIN as noted from Cr measurements between baseline and within 48 h. One patient who developed an elevated Cr level had a known history of chronic renal insufficiency (Cr > 1.5 mg/dl) and two had baseline Cr levels within the normal range. An additional CT angiogram was obtained in 44 patients, none of which developed CIN. Female gender and diabetes were not associated with a higher risk of developing CIN. Conclusions The risk of developing CIN is low among patients with acute stroke who undergo emergency endovascular treatment. Treatment of acute stroke should be performed irrespective of Cr levels.

P-021 TREVO Stent-Retriever Acute Stroke (TRACK) Post-marketing Registry: Interim Revascularization and Clinical Outcome Results Compared to TREVO-2 and NASA Registry

Immune‐mediated myopathies are a heterogeneous group of chronic autoimmune disorders. Autoantibodies associated with this disease complex are classified into myositis‐associated and myositis‐specific. Anti‐tRNA synthetase antibodies are the most well known of the myositis‐specific antibodies. Previous reports have revealed an association of tRNA synthetase autoantibodies with systemic connective tissue disorders.

Coil Embolization of Wide-Neck Bifurcation Aneurysms Using a Single-Balloon Microcatheter.

BACKGROUND AND PURPOSE Epidural injections are commonly utilized procedure in pain clinics; these procedures are not without complications. We present a rare air entrapment within the substance of the spinal cord causing symptoms of myelopathy. METHODS Report of a case. RESULTS A 56-year-old woman with chronic cervical pain underwent an elective cervical epidural injection. A small amount of Lidocaine was injected at the left cervical 7 to test needle patency; she immediately complained of severe cervical pain radiated to the left upper and lower extremities. The procedure was immediately terminated and needle was removed. Post-operative neurological examination revealed mild left lower extremity weakness and left hemiataxia. An immediate MRI of the cervical spine showed an air bubble within the cervical spinal cord that has resolved on the following imaging. The clinical syndrome also completely resolved. CONCLUSION Although rare, epidural cervical injection can be complicated by air myelopathy.

Endovascular Treatment of Cerebral Sinus Thrombosis

Background Although industry sponsored trials for newer mechanical thrombectomy devices for treatment of acute ischemic stroke (AIS) are promising, limited post-marketing data exist on the use of the TREVO device in every day clinical practice. Objective The ongoing TREVO Stent-Retriever Acute Stroke (TRACK) Registry aimed to assess the real-world safety, angiographic, and clinical efficacy of the TREVO device in comparison to the results from the TREVO-2 clinical trial and post-marketing North American SOLITAIRE Stent-Retriever Acute (NASA) Stroke Registry. Design/methods The TRACK Registry recruited clinical sites within the USA. Demographic, clinical, angiographic, and outcome data on patients treated with the TREVO device were collected. Symptomatic intracranial haemorrhage (sICH) was defined as any parenchymal hematoma, SAH, or IVH associated with a worsening of the NIHSS score by ≥4 within 24 h. The primary outcome was achieving TICI ≥2a revascularization. Secondary outcomes were mRS at 3 months, mortality, and sICH. Results 12 centers contributed data on 93 patients for this interim analysis. Baseline demographics were: women 61.3% (57/93), white 78.5% (73/93), mean age 64.9 ± 17.8 years, median baseline NIHSS of 17 (IQR 14–22), mean fluoroscopic time 37.5 ± 31.9 min, and a mean procedure time of 101 ± 69.1 min. The TICI ≥ 2a and TICI ≥ 2b revascularization rates were 85.6% (77/90) and 65.6% (59/90), compared to the operator reported TICI ≥ 2a rate of 85% in TREVO-2 and 87.5% in NASA, and TICI ≥ 2b rate of 72.5% in NASA. A good outcome of mRS ≤ 2 was demonstrated in 43.0% (40/93), compared to 40% (TREVO-2) and 42% (NASA). The rate of sICH was 8.4% (7/83), compared to 4% (TREVO-2) and 9.9% NASA. 90-day mortality was 21.5% (20/93) versus 29% in TREVO-2 and 30.2% in NASA. Conclusion The investigator initiated post marketing TRACK Registry demonstrates that the TREVO stent-retriever performance in clinical practice is comparable to the TREVO-2 trial and post-marketing NASA Registry. Disclosures O. Zaidat: 1; C; Stryker Neurovascular. A. Castonguay: None. E. Veznedaroglu: None. M. Binning: None. A. Alshekhlee: None. M. Abraham: None. S. Mehta: None. R. El Khoury: None. A. Majjhoo: None. E. Lin: None. M. Kabbani: None. M. Froehler: None. T. Nguyen: None.

Contents Vol. 4, 2015

Background: Coil embolization of wide-neck cerebral aneurysms frequently requires stent or balloon assistance. Such approaches to coil embolization increase the procedural complexity, adding risk and cost. Objective: To describe a series of coil embolization procedures performed using a single-balloon microcatheter to treat wide-neck aneurysms and establish the safety, feasibility and efficacy of this technique. Methods: A retrospective review was performed to identify cases in which the Ascent balloon (Codman Neurovascular, Raynham, Mass., USA) was used as a single-balloon microcatheter for aneurysm coil embolization at two institutions. Clinical, demographic and angiographic data were obtained, and aneurysm volumes as well as packing densities (PD) were calculated. Results: Eight cerebral aneurysms were treated using this technique. Six of these were unruptured. The aneurysms had an average neck diameter of 3.7 mm, and the maximum dimension ranged from 5 to 11 mm, with a mean of 7.5 mm. The mean aspect ratio was 2.07. The mean volume of the aneurysms was 180.38 mm3. The average PD achieved in these 8 aneurysms was 41.79%. Complete occlusion with coil embolization [Raymond-Roy Occlusion Classification (RROC) 1] was achieved in all cases except one, where a small residual was left deliberately and the occlusion grade was RROC 2. There were no intraprocedural complications. Conclusion: This initial experience demonstrates the feasibility and immediate outcomes of a single-balloon microcatheter technique in coil embolization of wide-neck cerebral aneurysms. This technique may be used to achieve a high PD, comparable to that obtained with stent-assisted coiling or coiling alone, while avoiding permanent stent placement and potentially reducing thromboembolic complications.

E-072 Post-coital MCA Dissection Presenting with SAH: A Case Report and Review of the Literature

Cerebral venous thrombosis (CVT) is an infrequent, but increasingly recognized cause of stroke. It occurs in the setting of dehydration and hypercoagulable states and disproportionately affects women. Clinical presentations range from isolated headache to focal deficits and coma. While first-line therapy has traditionally focused on hydration and anticoagulation, endovascular treatment is increasingly effective and safe. The initial endovascular approaches focused on the infusion of thrombolytic agents, but have expanded to include mechanical disruption with a variety of devices, include the “stent-retriever” family. Suction thrombectomy has returned to favor with the advent of large inner diameter, highly navigable catheters.