Sudhakar R Satti

Delayed Migration of a Pipeline Embolization Device

BACKGROUND: Giant and complex aneurysms are increasingly treated with the Pipeline Embolization Device (PED). However, clinical experience with the device remains preliminary. OBJECTIVE: To report the first case of a delayed migration of an intracranial PED. METHODS: A 61-year-old woman with a known large right cavernous internal carotid artery aneurysm had a 3-month history of increasing retro-orbital pain. She underwent uneventful treatment of her aneurysm with the PED. RESULTS: Five months after the procedure, the patient’s pain recurred. On the routine 6-month follow-up angiography, there was proximal PED migration, with the distal end of the device projecting directly into the aneurysm and creating a jet of contrast against the aneurysm sac. The migration distance was more than 1 cm, and there was significant foreshortening of the device. A second, overlapping PED was successfully deployed within the first PED to bridge the neck of the aneurysm and redirect the flow jet away from the aneurysm sac. Complete resolution of the patient’s symptoms was noted 4 weeks later. CONCLUSION: Delayed proximal migration may occur after placement of a PED. Accurate stent sizing and adequate apposition to the vessel wall may minimize the occurrence of this undesirable phenomenon. If there is any concern regarding the position of the PED, early imaging follow-up may be indicated. ABBREVIATION: PED, Pipeline Embolization Device

Mechanical thrombectomy for pediatric acute ischemic stroke: review of the literature

Objective Given recent strongly positive randomized controlled adult mechanical thrombectomy trials, we sought to perform a comprehensive review of available literature on IA pediatric stroke intervention, with a focus on modern mechanical devices. Methods PubMed search for pediatric patients undergoing IA treatment of acute ischemic stroke (AIS) using modern devices between 2008 and 2015. 29 patients were included in this analysis. Results Average age was 10.3 years, 74.1% male, middle cerebral and basilar arteries represented 89.6% of 36 occluded vessels, and average pediatric stroke scale score of 18.1. Average time from symptom onset to intervention was 8.8 hours and 13.8% of patients received IV tissue plasminogen activator prior to mechanical thrombectomy. Stent retrievers were used in 58.6% of cases, the Penumbra system in 34.5%, and the Merci device in 27.6%. Modified Thrombolysis In Cerebral Infarction 2b/3 recanalization was achieved in 75.9% of cases. There were no major adverse events related to the intervention, although one procedure was associated with device malfunction without a definite change in long-term outcome. The average modified Rankin Scale (mRS) score was <1 (0.86) at the longest available follow-up period, based on clinical description or provided mRS score. Conclusions This study suggests that mechanical thrombectomy in pediatric patients presenting with high pediatric NIH Stroke Scale scores and proximal large vessel occlusion is associated with high recanalization rates and excellent clinical outcome, although this is a retrospective review and the sample size is too small to make any definitive conclusions. This study provides class IVC evidence that endovascular treatment of pediatric AIS increases the chance of a good clinical outcome.

TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry

Background Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice. Methods Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH). Results A total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90-day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH. Conclusion The TRACK Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations.

Dural venous sinus stenting for medically and surgically refractory idiopathic intracranial hypertension

Background Idiopathic intracranial hypertension (IIH) is a syndrome defined by elevated intracranial hypertension without radiographic evidence of a mass lesion in the brain. Dural venous sinus stenosis has been increasingly recognized as a treatable cause, and dural venous sinus stenting (DVSS) is increasingly performed. Methods A 5 year single-center retrospective analysis of consecutive patients undergoing DVSS for medically refractory IIH. Results There were 43 patients with a mean imaging follow-up of 6.5 months and a mean clinical follow-up period of 13.5 months. DVSS was performed as the first procedure for medically refractory IIH in 81.4% of patients, whereas 18.6% of patients included had previously had a surgical procedure (ventriculoperitoneal (VP) shunt or optic nerve sheath fenestration (ONSF)). Headache was present in all patients and after DVSS improved or remained stable in 69.2% and 30.8%, respectively. Visual acuity changes and visual field changes were present in 88.4% and 37.2% of patients, respectively. Visual field improved or remained unchanged in 92%, but worsened in 8% after stenting. There was a stent patency rate of 81.8%, with an 18.2% re-stenosis rate. Of the 43 procedures performed, there was a 100% technical success rate with zero major or minor complications. Conclusion Based on this single-center retrospective analysis, DVSS can be performed with high technical success and low complication rates. A majority of patients presented primarily with headache, and these patients had excellent symptom relief with DVSS alone. Patients presenting with visual symptoms had lower success rates, and this population, if stented, should be carefully followed for progression of symptoms.

Subclavian steal: Endovascular treatment of total occlusions of the subclavian artery using a retrograde transradial subintimal approach.

Introduction In symptomatic subclavian steal syndrome, endovascular treatment is the first line of therapy prior to extra-anatomic surgical bypass procedures. Subintimal recanalization has been well described in the literature for the coronary arteries, and more recently, in the lower extremities. By modifying this approach, we present a unique retrograde technique using a heavy tip microwire to perform controlled subintimal dissection. Methods We present two cases of symptomatic subclavian steal related to chronic total occlusion of the left subclavian artery and right innominate artery, respectively. Standard crossing techniques were unsuccessful. Commonly at this point, the procedures would be aborted and open surgical intervention would have to be pursued. In our cases, retrograde access was easily achieved via an ipsilateral retrograde radial artery, using controlled subintimal dissection and a heavy-tipped wire. Results We were able to easily achieve recanalization in both attempted cases of chronic total occlusion of the subclavian and innominate artery, using a retrograde radial subintimal approach. Subsequent stent-supported angioplasty resulted in complete revascularization. No major complications were encountered during the procedures; however, one patient did develop thromboembolic stroke secondary to platelet aggregation to the stent graft, 9 days post-procedure. Conclusions Endovascular treatment is considered the first-line intervention in medically refractory patients with symptomatic subclavian steal syndrome. In the setting of chronic total occlusions, a retrograde radial subintimal approach using a heavy tip wire for controlled subintimal dissection is a novel technique that may be considered when standard approaches and wires have failed.

Basilar artery perforator aneurysms (BAPAs): review of the literature and classification

Basilar artery perforator aneurysms (BAPAs) are an uncommon subtype of perforating artery aneurysms, with only 18 published cases since their initial description in 1996 by Ghogawala et al. To date, there are only seven published cases of ruptured BAPAs treated using endovascular techniques. Given the rarity of these aneurysms, the natural history and ideal approach to treatment has not been established. We describe a new endovascular approach to treating these aneurysms using staged telescoping stents, summarize all published cases of BAPAs, and present a unique classification system to enable future papers to standardize descriptions.

O-004 Analysis of M2 Occlusions within TREVO Acute Ischemic Stroke (TRACK) stent-retriever Thrombectomy Registry

Background and purpose Several recent randomized clinical trials have demonstrated the safety and efficacy of mechanical thrombectomy with stent retrievers for acute ischemic stroke patients with anterior circulation occlusions. However, these trials have limited enrollment of patients with M2 occlusions. Here, we sought to examine the clinical and angiographic outcomes of patients with M2 occlusions in the Trevo Acute Ischemic Stroke (TRACK) stent-retriever thrombectomy multicenter registry. Methods Data from the investigator-initiated TRACK Registry (631 consecutive AIS patients, 23 clinical centers) was used to examine and compare demographic, clinical, and angiographic outcomes of patients with M1 versus M2 occlusions who were treated with TREVO as first treatment device. Results Of the 631 patients enrolled in the TRACK registry, 84 (13.3%) had M2 and 344 (54.5%) had M1 occlusions. Mean age was similar between the M1 and M2 cohorts, 66.5 ± 14.4 and 64.7 ± 3.8 years (p = 0.34), respectively. M2 patients had a lower median baseline NIHSS at presentation (14 (IQR 7–9) versus 18(IQR 14–22), p ≤ 0.0001). Time of onset to groin puncture (347 ± 237.4 and 361 ± 232.3, p = 0.63) and total procedural time (85.9 ± 49.9 and 78.3 ± 64.5, p = 0.4) was similar between the M1 and M2 cohorts. The number of passes with TREVO device was greater in the M1 cohort (Median, 2 (IQR 1–3) versus 1(IQR 1–2), p = 0.01) as well as use of rescue therapy (20.2% versus 9.8%, p = 0.03). Patients with M2 occlusions achieved a higher rate of TICI 3 revascularization after the 1st pass with TREVO device compared to those with M1 occlusions (55.8% versus 40.4%, p = 0.01). There was no significant difference in time to revascularization (78.6 ± 50.7 versus 71.6 ± 45.3, p = 0.2), revascularization success (≥TICI 2 b) (80.5% versus 76.2%, p = 0.4), symptomatic intracranial hemorrhage (5.6% versus 6.0%, p = 0.9), 90 day modified Rankin Scale score 0–2 (51.0% versus 57.4%, p = 0.35), or mortality (16.1% versus 13.2%, p = 0.6) between the M1 and M2 groups, respectively. Conclusions Patients with M2 Occlusions are more likely to achieve complete recanalization from the first pass with Trevo stent retriever device than M1 occlusion. In addition, the M2 cohort had a numerically higher rate of good clinical outcome and less rate of mortality than M1 group. This substudy is limited by lack of a control M2 group without mechanical thrombectomy. Disclosures A. Castonguay: None. R. Nogueira: None. J. English: None. S. Satti: None. H. Farid: None. E. Veznedaroglu: None. M. Binning: None. A. Puri: None. N. Vora: None. R. Budzik: None. G. Dabus: None. I. Linfante: None. V. Janardhan: None. A. Alshekhlee: None. M. Abraham: None. R. Edgell: None. M. Taqi: None. R. El Khoury: None. M. Mokin: None. M. Mokin: None. A. Majjhoo: None. M. Kabbani: None. M. Froehler: None. I. Finch: None. S. Ansari: None. R. Novakovic: None. T. Nguyen: None. O. Zaidat: None.

Discontinuation of oral anticoagulation preceding acute ischemic stroke--prevalence and outcomes: Comprehensive chart review.

Abstract Introduction: Oral anticoagulants (OAC) are the therapy of choice to prevent thromboembolism in patients at risk. Discontinuation of OAC prior to elective medical and surgical procedures may reduce the risk of bleeding, but may expose patients to increased risk of thromboembolism and ischemic stroke. The current public health burden of ischemic strokes associated with OAC discontinuation is unknown. We aimed to study the prevalence OAC discontinuation in patients who presented with acute ischemic stroke as well as the outcomes of these strokes. Methods: Retrospective cross-sectional study by intensive chart review of all acute ischemic stroke patients over 6 months in a large tertiary care community hospital. Results: A total of 431 patients with acute ischemic stroke were admitted during study period, of which 11 (2.6%) had OAC discontinuation within 120 days prior to the index admission. Several strokes occurred after relatively brief discontinuations. The patient group with discontinuation was older, had higher comorbidities and also had a clinically significant stroke and resulting higher mortality and morbidity. Conclusion: About 2.6% or 1 in every 38 of all ischemic stokes occurred after OAC discontinuation. Strokes occurring after OAC discontinuation also have higher mortality and morbidity. Our data suggest that any planned discontinuation of OAC, however brief, should be carefully considered.

Intercavernous Carotid Artery Aneurysm

A 76-year-old woman presented to the Emergency Department (ED) with a 1-week history of inability to move her left eye and lid lag. Her symptoms were initially mild but had been progressively worsening over the preceding several days. After a discussion with her primary care provider, she was prompted to go to the ED for further evaluation. She reported no headache, nausea, or vomiting, and denied having similar symptoms in the past. On physical examination, the patient was afebrile and had normal vital signs. She had a midline left pupil with ptosis and complete loss of extraocular movements. Her pupils were 4 mm bilaterally, the left was sluggishly reactive, and her visual acuity out of the affected eye was grossly normal. Her right eye appeared to be unaffected. She had no other cranial nerve deficits and was otherwise neurologically intact. A noncontrast head computed tomography scan demonstrated a peripherally calcified mass in the left cavernous sinus (Figure 1). Contrast-enhanced magnetic resonance angiography was then performed, showing a 10 15 18-mm aneurysm of the intercavernous portion of the left internal carotid artery (Figure 2.) The patient was subsequently admitted to the Medicine service, and a consult was placed to Neurointerventional Surgery.

Dural venous sinus stenting for idiopathic intracranial hypertension: An updated review

BACKGROUND Dural venous sinus stenting (DVSS) is an accepted treatment option in selected patients with medically refractory idiopathic intracranial hypertension and obstructive venous outflow physiology prior to cerebrospinal flow diversion (CSFD) surgery. There are no randomized controlled studies focusing on outcomes and complication rates for dural venous sinus stenting. PURPOSE We present the largest comprehensive meta-analysis on DVSS for idiopathic intracranial hypertension (IIH) focusing on success rates, complications, and re-stenting rates to date. We also present a simplified approach to direct retrograde internal jugular vein (IJ) access for DVSS that allows for expedited procedures. MATERIALS AND METHODS We performed a retrospective electronic PubMed query of all peer-reviewed articles in the last 15 years between 2003 to 2018. We included all patients who underwent dural venous sinus stenting for a medically refractive IIH and excluded articles without sufficient data on outcomes, complication rates and re-stenting rates. We also evaluated and compared outcomes in patients undergoing direct retrograde IJ access DVSS to traditional transfemoral vein access. RESULTS A total of 29 papers and 410 patients who underwent DVSS met criteria for inclusion. DVSS was associated with high technical success [99.5%], low rates of repeated procedure [10%], and low major complication rates [1.5%]. CONCLUSION Our retrospective comprehensive review of DVSS for medically refractory IIH suggests that stenting in appropriately chosen patients is associated with low complication rates, high technical success, and low repeat procedure rates.