First Human Evaluation of Endothelial Healing after a Pipeline Flex Embolization Device with Shield Technology Implanted in Posterior Circulation Using Optical Coherence Tomography / 신경중재치료의학

A 64-year-old female presented with an incidentally-discovered right posterior inferior cerebral artery (PICA) aneurysm, initially treated in 2015 by simple coiling. Follow-up demonstrated significant coil compaction that required retreatment. Retreatment was done uneventfully using a Pipeline embolization device (PED) shield deployed starting from the basilar artery and ending at the V4 segment of the vertebral artery. Eight-weeks post-deployment, a follow-up digital subtraction imaging (DSA) and intravascular imaging with optical coherence tomography were obtained. The intravascular imaging demonstrated that the flow diverter had good wall apposition and concentric neointimal growth over the braid with exception to the areas that the PED was not in contact with the endothelial wall, such as at the right PICA ostium and at the vertebrobasilar junction. The entire procedure was safe, and the patient had no complications. In this article, we describe for the first time the assessment of the status of endothelial “healing” of the PED shield at 8-weeks.

Mobile Real-time Tracking of Acute Stroke Patients and Instant, Secure Inter-team Communication - the Join App / 신경중재치료의학

PURPOSE: The primary correlate to survival and preservation of neurologic function in patients suffering from an acute ischemic stroke is time from symptom onset to initiation of therapy and reperfusion. Communication and coordination among members of the stroke team are essential to maximizing efficiency and subsequently early reperfusion. In this work, we aim to describe our preliminary experience using the Join mobile application as a means to improve interdisciplinary team communication and efficiency. MATERIALS AND METHODS: We describe our pilot experience with the initiation of the Join mobile application between July 2015 and July 2016. With this application, a mobile beacon is transported with the patient on the ambulance. Transportation milestone timestamps and geographic coordinates are transmitted to the treating facility and instantly communicated to all treatment team members. The transport team / patient can be tracked en route to the treating facility. RESULTS: During our pilot study, 62 patients were triaged and managed using the Join application. Automated time-stamping of critical events, geographic tracking of patient transport and summary documents were obtained for all patients. Treatment team members had an overall favorable impression of the Join application and recommended its continued use. CONCLUSION: The Join application is one of several components of a multi-institutional, interdisciplinary effort to improve the treatment of patients with acute ischemic stroke. The ability of the treatment team to track patient transport and communicate with the transporting team may improve reperfusion time and, therefore, improve neurologic outcomes.

Progressive Deconstruction of a Distal Posterior Cerebral Artery Aneurysm Using Competitive Flow Diversion / 신경중재치료의학

Progressive deconstruction is an endovascular technique for aneurysm treatment that utilizes flow diverting stents to promote progressive thrombosis by diverting blood flow away from the aneurysm's parent vessel. While the aneurysm thromboses, collateral blood vessels develop over time to avoid infarction that can often accompany acute parent vessel occlusion. We report a 37-year-old woman with a left distal posterior cerebral artery aneurysm that was successfully treated with this strategy. The concept and rationale of progressive deconstruction are discussed in detail.

Monoplane 3D Overlay Roadmap versus Conventional Biplane 2D Roadmap Technique for Neurointervenional Procedures / 신경중재치료의학

PURPOSE: We investigated whether a 3D overlay roadmap using monoplane fluoroscopy offers advantages over a conventional 2D roadmap using biplane fluoroscopy during endovascular aneurysm treatment. MATERIALS AND METHODS: A retrospective chart review was conducted for 131 consecutive cerebral aneurysm embolizations by three neurointerventionalists at a single institution. Allowing for a transition period, the periods from January 2012 to August 2012 (Time Period 1) and February 2013 to July 2013 (Time Period 2) were analyzed for radiation exposure, contrast administration, fluoroscopy time, procedure time, angiographic results, and perioperative complications. Two neurointerventionalists (Group 1) used a conventional 2D roadmap for both Time Periods, and one neurointerventionalist (Group 2) transitioned from a 2D roadmap during Time Period 1 to a 3D overlay roadmap during Time Period 2. RESULTS: During Time Period 2, Group 2 demonstrated reduced fluoroscopy time (p<0.001), procedure time (P=0.023), total radiation dose (p=0.001), and fluoroscopy dose (P=0.017) relative to Group 1. During Time Period 2, there was no difference of immediate angiographic results and procedure complications between the two groups. Through the transition from Time Period 1 to Time Period 2, Group 2 demonstrated decreased fluoroscopy time (p<0.001), procedure time (p=0.022), and procedure complication rate (p=0.041) in Time Period 2 relative to Time Period 1. CONCLUSION: The monoplane 3D overlay roadmap technique reduced fluoroscopy dose and fluoroscopy time during neurointervention of cerebral aneurysms with similar angiographic occlusions and complications rate relative to biplane 2D roadmap, which implies possible compensation of limitations of monoplane fluoroscopy by 3D overlay technique.

Persistent Aneurysm Growth Following Pipeline Embolization Device Assisted Coiling of a Fusiform Vertebral Artery Aneurysm: A Word of Caution! / 신경중재치료의학

The complex morphology of vertebrobasilar fusiform aneurysms makes them one of the most challenging lesions treated by neurointerventionists. Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents. Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety. However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH). We report a rare case of persistent aneurysmal growth after coiling and placement of the Pipeline Embolization Device (PED; ev3, Irvine, California, USA) for SAH from a fusiform vertebral artery aneurysm. As consequences of aneurysm rupture can be devastating especially in patients with a prior SAH, the clinical relevance of recognizing and understanding such patterns of failure cannot be overemphasized as highlighted in the present case.

Ventriculoperitoneal Shunt in a Patient with Ruptured Blister Aneurysm Treated with Pipeline Embolization Device

Cerebral spinal fluid (CSF) diversion is frequently required in patients with aneurysmal subarachnoid hemorrhage who develop subsequent hydrocephalus. Procedures such as external ventricular drain (EVD) and ventriculoperitoneal shunt (VPS) usually carry a very low rate of complications. However, as flow diverting stents such as Pipeline Embolization Device (PED) become more widely available, flow diverters are being used in treatment of some ruptured complex aneurysms. EVD and VPS placement in the setting of dual antiplatelet therapy (DAT) in these patients are associated with a significant risk of intracranial hemorrhage. We describe a management strategy and surgical technique that can minimize hemorrhagic complications associated with VPS in patients on DAT after treatment with flow diverting stents.

Manual Aspiration Technique to Retrieve a Prematurely Detached Coil during Cerebral Aneurysm Embolization / 신경중재치료의학

Coil herniation, premature deployment, and fracture are procedure associated complications of endovascular aneurysm embolization that optimally necessitate coil retrieval when feasible. Several published techniques describe different strategies for managing coil complications including various snare retrieval devices, alligator retrieval devices, stent fixation, and open surgical resection of coils when distal blood flow is compromised. We report a novel technique employed to retrieve a prematurely detached coil during an aneurysm embolization using a syringe fixed to the microcatheter to carefully aspirate a loose coil with direct fluoroscopic visualization. This technique can only be utilized in the circumstance where the proximal end of the coil remains in the microcatheter. Conventional techniques of coil retrieval and stenting are discussed and compared to the rational for using the manual aspiration technique.

Aneurysm Coil Embolization Using a 1.5-Fr Distal Outer Diameter Microcatheter / 신경중재치료의학

The current assortment of microcatheters widely used for aneurysm coil embolization may not be well suited for several anatomic variants, including excessive vascular tortuosity and small aneurysms less than 3 mm. Longer microcatheters designed with a smaller caliber that can accommodate and deliver coils may be of use in these situations. This case series and literature review illustrates the advantages and limitations of the Marathon microcatheter (Covidien, Irvine, CA, USA) when used for coil embolization of cerebral aneurysms. Despite some technical compromises including the distal marker, length, and the risk of buckling, the Marathon microcatheter was able to adequately deliver coils to achieve satisfactory occlusion of cerebral aneurysms. We found unique advantages with regards to length and smaller distal outer diameter (OD). These results may serve as a guide for the further development of a microcatheter used for coil embolization that has the features of a smaller distal OD and longer length.

Successful Mechanical Thrombectomy in a 2-Year-Old Male Through a 4-French Guide Catheter / 신경중재치료의학

A 2-year-old boy with hypoplastic left heart syndrome that required multiple cardiovascular surgeries and a heterozygous prothrombin G20210A mutation with resulting thrombophilia maintained on warfarin presented with acute right middle cerebral artery (MCA) infarction manifesting as a left hemiplegia. An MRI revealed a complete occlusion of the right M1 segment with an area of restricted diffusion in the right basal ganglia representing only a small area of acute infarction. Patchy areas of subacute infarction were also present in the right MCA territory. He underwent endovascular mechanical thrombectomy with a stent retriever. This is an account of a successful mechanical thrombectomy performed in the youngest patient reported in the English literature to date.

Ultrasound-Guided Posterolateral Approach for Midline Calcified Thoracic Disc Herniation

OBJECTIVE: Symptomatic thoracic disc herniation often requires prompt surgical treatment to prevent neurological deterioration and permanent deficits. Anterior approaches offer direct visualization and access to the herniated disc and anterior dura but require access surgeons and are often associated with considerable postoperative pain and pulmonary complications. A disadvantage with using posterior approaches in the setting of central calcified thoracic disc herniation however, has been the limited visualization of anterior dura and difficulty to accurately assess the extent of decompression. METHODS: We report our experience with intraoperative ultrasound (US) guidance during a modified posterior transpedicular approach for removal of a central calcified thoracic disc herniation with a review of pertinent literature. RESULTS: The herniated thoracic disc was successfully removed with posterior approach with the aid of intraoperative US. The patient had significant neurological improvement at three months follow-up. CONCLUSION: Intraoperative ultrasound is a simple yet valuable tool for real-time imaging during transpedicular thoracic discectomy. Visualization provided by intraoperative US increases the safety profile of posterior approaches and may make thoracotomy unnecessary in a selected group of patients, especially when a patient has existing pulmonary disease or is otherwise not medically fit for the transthoracic approach.

Symptomatic Cerebral Air Embolism During Stent-assisted Coiling of an Unruptured Middle Cerebral Artery Aneurysm: Intraoperative Diagnosis and Management of a Rare Complication

Symptomatic cerebral air embolism during cerebral angiography is extremely rare. We report on the case of a 69-year-old woman undergoing elective stent-assisted coiling of an unruptured right middle cerebral artery (MCA) bifurcation aneurysm, who was found to have severe attenuation of somatosensory evoked potential (SSEP) and electroencephalography (EEG) during the procedure. Intra-operative DynaCT showed hypodense cortical vessels consistent with cerebral air embolism. Diagnostic and management strategies for this rare complication are reviewed.

Delayed Vascular Claudication Following Diagnostic Cerebral Angiography: A Rare Complication of the AngioSeal Arteriotomy Closure Device

With rapidly increasing numbers of neuroendovascular procedures performed annually in recent years, use of arterial closure devices after femoral artery access has been exceedingly common secondary to reduced time to hemostasis, decreased patient discomfort, earlier mobilization, and shortened hospital stay. Although uncommon, use of these devices can lead to a different spectrum of complications, as compared to manual compression. Ischemic symptoms following the use of these devices can have unexpected clinical sequelae and can occur in a delayed fashion. Awareness and recognition of such complications is important with the dramatically increased use of these devices in recent years. We report on a case of delayed vascular complication manifesting as vascular claudication following use of the AngioSeal closure device.

Treatment of a Ruptured Vertebrobasilar Fusiform Aneurysm Using Pipeline Embolization Device

Treatment options of ruptured vertebrobasilar fusiform aneurysms (VFA) are limited and often carry significant mortality and morbidity. We report the use of Pipeline Embolization Device (PED) to successfully treat a patient with a ruptured vertebrobasilar fusiform aneurysm (VFA) who presented with subarachnoid hemorrhage (SAH). A 73 year-old man with a history of cardiac stent placement seven days earlier presented with Hunt-Hess II SAH. He was taking aspirin and clopidogrel. Computed tomography angiogram revealed a large vertebrobasilar fusiform aneurysm. Microsurgical treatment options are technically challenging and carry high risk. He underwent endovascular treatment of the ruptured VFA using overlapping PEDs. Five PEDs were placed in a telescoping fashion to reconstruct the affected portions of the left vertebral and basilar arteries. An additional 2-mm blister aneurysm in the right vertebral artery was also discovered during the conventional cerebral angiography and was treated with one additional PED. The patient remained neurologically intact after the procedure. He was continued on aspirin and clopidogrel. Follow-up magnetic resonance imaging at three months demonstrated patency of the stents without any evidence of ischemic change. Follow-up conventional cerebral angiogram at six months demonstrated thrombosis of the VFA and reconstruction of the vertebrobasilar system. The patient remained clinically well. An endovascular approach using PEDs can be a safe and effective treatment option for ruptured VFA in selected cases.