Enhanced staff communication and reduced near-miss errors with a neurointerventional procedural checklist.

INTRODUCTION: Over the past several decades, checklists have emerged in a variety of different patient care settings to help reduce medical errors and ensure patient safety. To date, there have been no published accounts demonstrating the effectiveness of checklists designed specifically for the unique demands of neurointerventional procedures. METHODS: A three-part, 20-item checklist was developed specific to neurointerventional procedures using the WHO surgical checklist as a template. Staff members (nurses, radiation technologists and physicians) were surveyed regarding near-miss adverse events and the quality of communication immediately following each neurointerventional procedure for 4 weeks prior to implementation of the checklist and again for 4 weeks after using the checklist. Staff members were asked to complete final surveys at the end of the study period. RESULTS: 71 procedures were performed during the 4 weeks prior to checklist implementation and 60 procedures were performed during the 4 weeks after institution of the checklist. Post-checklist surveys indicated significantly improved communication compared with pre-checklist surveys (χ(2) 29.4, p<0.001). The number of adverse events was lower after checklist implementation for eight of the nine adverse event types (not individually significant), but the total number of adverse events was significantly lower after checklist implementation (χ(2) 11.4, p=0.001). Final staff surveys were uniformly positive with 95% of individuals indicating that the checklist should be continued in the department. CONCLUSIONS: Use of a neurointerventional procedural checklist resulted in statistically significant improvements in team communication and a significant reduction in total adverse events, with uniformly positive staff feedback.

Occurrence of angiographic femoral artery complications after vascular closure with Mynx and AngioSeal.

INTRODUCTION: There have been recent reports of high vascular complication rates after the use of the Mynx vascular closure device (VCD). At our institution, vascular complications due to these devices have rarely been encountered. A study was undertaken to retrospectively compare angiographic abnormalities seen after femoral artery closure by both the Mynx and AngioSeal VCDs to provide further insight into the risks associated with VCDs. METHODS: All adult patients who underwent deployment of either a Mynx or AngioSeal VCD and subsequently underwent repeat angiography within the next 30 days between 1 July 2010 and 1 April 2011 were reviewed. Two independent blinded radiologists compared blinded pre-procedure and follow-up femoral angiograms for the presence of pseudoaneurysm or other vascular abnormality. Hospital records were reviewed for major or minor complications of the groin site or femoral artery. RESULTS: Thirty patients (31 angiograms) underwent vascular closure with a Mynx and 57 patients (69 angiograms) received an AngioSeal. The average time elapse until repeat femoral angiography was 6.2 days (range 1-21, median 5.5 days) in the Mynx group and 6.3 days (range 0-30, median 5 days) in the AngioSeal group. Two pseudoaneurysms and one minor stenosis were identified in the AngioSeal group. No angiographic abnormalities were seen in the Mynx group. No intraluminal filling defects were demonstrated on any of the follow-up femoral angiograms. One patient who received an AngioSeal developed a delayed minor groin site hematoma that did not require surgical intervention. CONCLUSIONS: Angiographic complications were seen in only 3% of patients after closure with Mynx or AngioSeal VCDs. There were no clinically significant groin site or vascular complications. These data suggest that both VCDs are safe for use after angiography with a low rate of femoral artery complications.

Clinical course of nontraumatic, nonaneurysmal subarachnoid hemorrhage: a single-institution experience.

OBJECT: Angiogram-negative subarachnoid hemorrhage (SAH) accounts for 15% of nontraumatic SAH and has been reported with low morbidity and mortality rates. We report on a large series of patients with angiogram-negative SAH who experienced an atypical nonbenign clinical course. METHODS: Between December 2001 and November 2006, 95 patients with spontaneous nonaneurysmal SAH and negative initial angiographic evaluation were treated at the University of Florida. The authors retrospectively reviewed the patients' medical records and radiological images to determine associated morbidity and mortality. RESULTS: Aneurysms were found in 6 of the 95 patients on follow-up imaging after an initial negative angiogram (6.3% false negative rate); these patients were excluded leaving 89 patients as the study group. Hydrocephalus necessitating temporary CSF diversion developed in 22 of these patients (25%); 12 (13%) ultimately required permanent CSF diversion. Clinically significant vasospasm developed in 4 patients (4%), and 2 (2%) had cerebral infarctions. Three patients (3%) died. CONCLUSIONS: The authors' experience with a large series of angiogram-negative SAH patients who had an atypical nonbenign clinical course associated with hydrocephalus, vasospasm, stroke, and mortality differs significantly from previously published case series of angiogram-negative SAH.

Comparison of N-butyl cyanoacrylate and onyx for the embolization of intracranial arteriovenous malformations: analysis of fluoroscopy and procedure times.

OBJECTIVE: Intracranial arteriovenous malformations (AVM) may be managed through staged preoperative embolization and resection. Two commonly used liquid embolics are N-butyl cyanoacrylate (nBCA; Cordis Microvascular, Inc., New Brunswick, NJ) and Onyx (ev3, Inc., Irvine, CA). We sought to compare the utility of these agents in terms of fluoroscopy and procedure times. METHODS: All intracranial AVMs embolized from 2002 to 2006 at the University of Florida were included in this study. Patients were stratified into three treatment groups: nBCA, Onyx, and patients who received both nBCA and Onyx during separate embolizations. Cohorts were compared by sex, age, Spetzler-Martin grade, AVM volume, fluoroscopy time, procedure time, surgical blood loss, and complications. RESULTS: A total of 182 embolizations were performed on 88 patients (nBCA, 60 patients and 106 procedures; Onyx, 20 patients and 43 procedures; and nBCA/Onyx, eight patients and 16 nBCA and 17 Onyx procedures). There were no significant differences in patient demographics, AVM volumes, and Spetzler-Martin grades. Mean fluoroscopy and procedure times were increased for Onyx (57 min; 2.6 h) compared with nBCA (37 min; 2.1 h) embolizations (P < 0.0001 and P = 0.001, respectively). Cumulative mean fluoroscopy time was increased for Onyx (135 min) and nBCA/Onyx (180 min) cohorts relative to nBCA (64 min; P < 0.0001). Cumulative mean procedure time was increased in the nBCA/Onyx group (10.4 h) compared with nBCA (3.7 h) and Onyx (5.4 h; P < 0.0001). Seventy patients (80%) underwent AVM resection. No significant differences in surgical blood loss or complication rates were observed among the cohorts. CONCLUSION: Onyx AVM embolization requires increased fluoroscopy and procedure times compared with nBCA. Further investigation is necessary to justify increased radiation exposure and procedure time associated with Onyx.

Bottleneck factor and height-width ratio: association with ruptured aneurysms in patients with multiple cerebral aneurysms.

OBJECTIVE: Determining factors predictive of the natural risk of rupture of cerebral aneurysms is difficult because of the need to control for confounding variables. We studied factors associated with rupture in a study model of patients with multiple cerebral aneurysms, one aneurysm that had ruptured and one or more that had not, in which each patient served as their own internal control. METHODS: We collected aneurysm location, one-dimensional measurements, and two-dimensional indices from the computed tomographic angiograms of patients in the proposed study model and compared ruptured versus unruptured aneurysms. Bivariate statistics were supplemented with multivariable logistic regression analysis to model ruptured status. A total of 40 candidate models were evaluated for predictive power and fit with Wald scoring, Cox and Snell R2, Hosmer and Lemeshow tests, case classification counting, and residual analysis to determine which of the computed tomographic angiographic measurements or indices were jointly associated with and predictive of aneurysm rupture. RESULTS: Thirty patients with 67 aneurysms (30 ruptured, 37 unruptured) were studied. Maximum diameter, height, maximum width, bulge height, parent artery diameter, aspect ratio, bottleneck factor, and aneurysm/parent artery ratio were significantly (P < 0.05) associated with ruptured aneurysms on bivariate analysis. When best subsets and stepwise multivariable logistic regression was performed, bottleneck factor (odds ratio = 1.25, confidence interval = 1.11-1.41 for every 0.1 increase) and height-width ratio (odds ratio = 1.23, confidence interval = 1.03-1.47 for every 0.1 increase) were the only measures that were significantly predictive of rupture. CONCLUSION: In a case-control study of patients with multiple cerebral aneurysms, increased bottleneck factor and height-width ratio were consistently associated with rupture.

Endovascular surgery for proximal posterior inferior cerebellar artery aneurysms: an analysis of Glasgow Outcome Score by Hunt-Hess grades.

OBJECTIVE: Proximal posterior inferior cerebellar artery (PICA) aneurysms represent a subset of posterior circulation aneurysms that can be routinely treated with either clipping or coiling. The literature contains limited numbers of patients with proximal PICA aneurysms treated with endovascular surgery. We report our experience with endovascular surgery of proximal PICA aneurysms with emphasis on patients with poor Hunt-Hess grades. METHODS: We reviewed 31 consecutive patients with proximal PICA aneurysms who were treated with endovascular surgery. The following data were analyzed: age, sex, size of aneurysm, Hunt-Hess grade at presentation, Fisher grade at presentation, angiographic result after embolization, complications, number of days hospitalized, duration of follow-up, angiographic follow-up results, and Glasgow Outcome Score at follow-up. RESULTS: Excellent angiographic occlusion was achieved in 30 of 31 (97%) patients. Clinical follow-up with Glasgow Outcome Score was performed on every patient an average of 10 months later. Twenty-one of 31 (68%) patients had good outcomes (Glasgow Outcome Score I or II) at follow-up. Of the patients who presented with a favorable clinical grade (Hunt-Hess 0-III), 13 of 15 (87%) had good outcomes at follow-up. Of the patients who presented with a poor clinical grade (Hunt-Hess Grade IV or higher), 8 of 16 (50%) had good outcomes at follow-up. CONCLUSION: This series demonstrates the safety and efficacy of endovascular surgery for proximal PICA aneurysms. Many patients with poor Hunt-Hess grades from ruptured PICA aneurysms ultimately had a good outcome. This could be secondary to early, aggressive treatment of hydrocephalus and the minimally invasive nature of the endovascular approach.

The use of abciximab in the treatment of acute cerebral thromboembolic events during neuroendovascular procedures.

BACKGROUND: Recently, a great interest has emerged regarding the use of abciximab for treatment of stroke. Thromboembolic events that occur during neuroendovascular procedures represent a unique subset of stroke patients because definitive angiographic diagnosis and treatment can be performed immediately. The existing literature on this situation suggests excellent results; however, most publications are case reports, and the largest series is 13 cases. We report our experience using abciximab in the treatment of acute thromboembolic events that occur during neuroendovascular procedures. METHODS: We reviewed the last 1373 consecutive patients who underwent neuroendovascular procedures at the University of Florida from our prospectively maintained clinical database. Of these patients, 29 (2.11%) endovascular cases were complicated by acute cerebral thromboembolic events that were treated with abciximab. Abciximab was administered in less than 1 hour after the onset of the occlusion in every patient. The Thrombolysis In Myocardial Infarction (TIMI) scale was used to measure immediate angiographic outcome, and the Modified Rankin Scale (MRS) was used to measure clinical outcome at the time of follow-up. Independent outcome was defined as an MRS of 3 or less at follow-up. RESULTS: Angiographic improvement in the TIMI grade was achieved in 29 (81%) of 36 arteries. Three intracerebral hemorrhages occurred with abciximab when administered with concurrent mechanical clot disruption; in two of these hemorrhages, recombinant tissue plasminogen activator (r-tPA) was also administered. The mean follow-up time for the living cohort was 7.54 months. Twenty-four (83%) patients were independent at follow-up, 3 (10%) were dependent at follow-up, and 2 (7%) died. CONCLUSION: Abciximab appears to be safe and effective in the treatment of acute cerebral thromboembolic complications during neuroendovascular procedures.

Delayed exacerbation of third nerve palsy due to aneurysmal regrowth after endovascular coil embolization.

A 72-year-old woman with a painful left third cranial nerve palsy due to a basilar artery aneurysm situated between the superior cerebellar and posterior cerebral arteries was treated with Guglielmi detachable coils (GDCs). Despite a good initial angiographic result with a small residual neck and improvement in the ocular motility and pain, the patient experienced worsening of the third cranial nerve palsy 15 months later. Cerebral angiography confirmed coil compaction with aneurysmal regrowth. A second endovascular coil embolization resulted in complete obliteration of the aneurysm. The patient experienced complete resolution of the pain and partial resolution of the third cranial nerve palsy. In some patients, a small residual aneurysm neck after endovascular embolization therapy with GDCs can result in delayed aneurysmal regrowth due to coil compaction. Clinical manifestations may herald this dangerous regrowth.