Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience.

BACKGROUND: Randomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications. OBJECTIVE: To study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD. METHODS: Prospectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up. RESULTS: A total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2-20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3-14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke. CONCLUSION: Our study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

Changes in Neuroendovascular Procedural Volume During the COVID-19 Pandemic: An International Multicenter Study.

BACKGROUND AND PURPOSE: The effect of coronavirus disease 2019 (COVID-19) pandemic on performance of neuroendovascular procedures has not been quantified. METHODS: We performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January-April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID-19 cases per 100,00 population-into high and low prevalent regions. RESULTS: Between 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID-19 prevalent regions. The procedural volume reduction was mainly observed in March-April 2020. CONCLUSIONS: We provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.

The use of cangrelor in neurovascular interventions: a multicenter experience.

PURPOSE: Thromboembolic events represent the most common procedure-related complication associated with neurointerventions. Cangrelor is a potent, intravenous (IV), P2Y12-receptor antagonist with a rapid onset and offset presented as an alternative antiplatelet agent. We aim to evaluate the safety and effectiveness of IV cangrelor in neurovascular intervention. METHODS: This is a retrospective analysis of data from four cerebrovascular interventional centers. We identified patients who underwent acute neurovascular intervention and received cangrelor as part of their optimum care. Patients were divided into 2 groups: ischemic and aneurysm. Periprocedural thromboembolic events, hemorrhagic complications, and outcomes were analyzed. RESULTS: Sixty-six patients were included, 42 allocated into the ischemic group (IG), and 24 into aneurysm group (AG). The IG periprocedural symptomatic complication rate was 9.5%, represented by 3 postoperative intracranial hemorrhages and 1 retroperitoneal hematoma. At discharge, 47.6% had a favorable outcome and the mortality rate was 2.4%, related to clinical deterioration of a large infarct. In the AG, 4.2% had a periprocedural complication during or after cangrelor infusion, represented by an intracranial hemorrhage in an initially ruptured aneurysm. Favorable clinical outcome was seen in 56.2% and 87.7% of ruptured and unruptured aneurysms, respectively, upon discharge. CONCLUSIONS: Cangrelor may be a feasible alternative for patients requiring immediate intervention with the use of endoluminal devices. It allows the possibility for a secure transition to long-term ticagrelor and progression to surgery in the setting of unexpected complications.

Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report.

BACKGROUND: Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications. CASE DESCRIPTION: We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention. CONCLUSIONS: This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.

Prolonged Microcatheter-Based Local Thrombolytic Infusion as a Salvage Treatment After Failed Endovascular Treatment for Cerebral Venous Thrombosis: A Multicenter Experience.

BACKGROUND AND PURPOSE: To determine the effectiveness of prolonged microcatheter-based local thrombolytic infusion in treatment of patients with cerebral venous thrombosis who achieved no or suboptimal recanalization with transvenous endovascular treatment. METHODS: Data collection: Prospectively registries supplemented by retrospective review. SETTINGS: Three hospitals with tertiary referral base. PATIENTS: Patients who underwent transvenous endovascular treatment for cerebral venous thrombosis. INTERVENTION: Prolonged microcatheter-based local thrombolytic infusion of alteplase at the rate of 0.5-1 mg/h in patients in whom initial angiographic outcome was deemed suboptimal, either due to incomplete or no recanalization. RESULTS: Serial angiograms were performed to assess treatment response as follows: grade I, partial recanalization of one or more occluded dural sinuses with improved flow or visualization of branches; grade II, complete recanalization of one sinus but persistent occlusion of the other sinuses (A-no residual flow, B-nonocclusive flow); grade III, complete recanalization. Clinical outcome was determined at 1-3 months using modified Rankin scale. A total of 14 patients underwent 15 transvenous endovascular treatments. Initial treatment was considered suboptimal in 12/15 procedures due to no recanalization in five (grade 0), partial recanalization (grade I) in four, complete recanalization of one sinus but persistent occlusion of the other sinuses (grade 2A in two and 2B in one). A prolonged microcatheter-based local recombinant tissue plasminogen activator infusion was used following ten of the 15 procedures for a median duration of 18 h (range 13-22 h). Follow-up angiography demonstrated complete recanalization in four procedures and improvement in grades of partial recanalization in six procedures (final grades 2A in three and 2B in three procedures). None of the patients developed new symptomatic intracranial hemorrhage associated with local thrombolytic infusion. At follow-up, patients in five of ten procedures had achieved a modified Rankin scale of 0 and one patient had achieved a score of 1 (no neurological deficits but had residual headaches). CONCLUSION: Prolonged microcatheter-based local thrombolytic infusion appeared to be effective treatment in patients who have suboptimal response to acute transvenous endovascular treatment without any additional adverse events.

Open-Label Phase I Clinical Study to Assess the Safety and Efficacy of Cilostazol in Patients Undergoing Internal Carotid Artery Stent Placement.

BACKGROUND: One-month dual antiplatelet treatment, with aspirin and clopidogrel, following internal carotid artery stent placement is the current standard of care to prevent in-stent thrombosis. Cilostazol, an antiplatelet drug, has been demonstrated to have a safety profile comparable to aspirin and clopidogrel. OBJECTIVE: To evaluate the safety and clinical efficacy of cilostazol and aspirin therapy following internal carotid artery stent placement up to 1 month postprocedure. METHODS: A phase I open-label, nonrandomized two-center prospective study was conducted. All subjects received aspirin (325 mg/day) and cilostazol (200 mg/day) 3 days before extracranial stent placement. Two antiplatelet agents were continued for 1 month postprocedure followed by aspirin daily monotherapy. The primary efficacy end point was the 30-day composite occurrence of death, cerebral infarction, transient ischemic attack, and in-stent thrombosis. The primary safety end point was bleeding. RESULTS: Twelve subjects (mean age ± SD, 66 ± 12 years; 9 males) were enrolled and underwent internal carotid artery angioplasty and stent placement. None of the subjects who successfully followed the study protocol experienced any complications at the 1- and 3-month follow-ups. One patient had a protocol deviation due to concurrent use of enoxaparin (1 mg/kg twice daily) in addition to aspirin and cilostazol, resulting in a fatal symptomatic intracerebral hemorrhage following successful stent placement on postprocedure day 1. One patient discontinued cilostazol after the first dose secondary to dizziness. CONCLUSION: The use of cilostazol and aspirin for internal carotid artery stent placement appears to be safe, but protocol compliance needs to be emphasized.

Automated CT Perfusion for Ischemic Core Volume Prediction in Tandem Anterior Circulation Occlusions.

BACKGROUND/AIM: CT perfusion (CTP) predicts ischemic core volumes in acute ischemic stroke (AIS); however, assumptions made within the pharmacokinetic model may engender errors by the presence of tracer delay or dispersion. We aimed to evaluate the impact of hemodynamic disturbance due to extracranial anterior circulation occlusions upon the accuracy of ischemic core volume estimation with an automated perfusion analysis tool (RAPID) among AIS patients with large-vessel occlusions. METHODS: A prospectively collected, interventional database was retrospectively reviewed for all cases of endovascular treatment of AIS between September 2010 and March 2015 for patients with anterior circulation occlusions with baseline CTP and full reperfusion (mTICI3). RESULTS: Out of 685 treated patients, 114 fit the inclusion criteria. Comparison between tandem (n = 21) and nontandem groups (n = 93) revealed similar baseline ischemic core (20 ± 19 vs. 19 ± 25 cm(3); p = 0.8), Tmax >6 s (175 ± 109 vs. 162 ± 118 cm(3); p = 0.6), Tmax >10 s (90 ± 84 vs. 90 ± 91 cm(3); p = 0.9), and final infarct volumes (45 ± 47 vs. 37 ± 45 cm(3); p = 0.5). Baseline core volumes were found to correlate with final infarct volumes for the tandem (r = 0.49; p = 0.02) and nontandem (r = 0.44; p < 0.01) groups. The mean absolute difference between estimated core and final infarct volume was similar between patients with and those without (24 ± 41 vs. 17 ± 41 cm(3); p = 0.5) tandem lesions. CONCLUSIONS: The prediction of baseline ischemic core volumes through an optimized CTP analysis employing rigorous normalization, thresholding, and voxel-wise analysis is not significantly influenced by the presence of underlying extracranial carotid steno-occlusive disease in large-vessel AIS.

Endovascular Therapy for Large Vessel Stroke in the Elderly: Hope in the New Stroke Era.

BACKGROUND AND PURPOSE: Acute ischemic stroke (AIS) in the elderly encompasses approximately one-third of all AIS cases. Outcome data have been for the most part discouraging in this population. We aim to evaluate the outcomes in a large contemporary series of elderly patients treated with thrombectomy. METHODS: Retrospective analysis of a single-center endovascular database for consecutive elderly (≥80 years) patients treated for anterior circulation large vessel occlusion AIS between September 2010 and April 2015. Univariate- and multivariate analyses were performed to identify the predictors of good clinical outcome (90-day modified Ranking Scale [mRS] ≤2). Receiver operating characteristic curves were used to calculate the optimal final infarct volume (FIV) threshold to predict good outcomes. RESULTS: A total of 111 patients met our inclusion criteria (mean age 84.8 ± 4.2 years; National Institutes of Health Stroke Scale [NIHSS] score 19.1 ± 5.6; time from last-known normal to puncture, 349.6 ± 246.6 min; 33% male; 68% Alberta Stroke Program Early CT Score [ASPECTS] ≥8). The rates of successful reperfusion (modified treatment in cerebral ischemia ≥2b), symptomatic intracranial hemorrhage and 90-day mortality were 80%, 7% and 41%, respectively. The overall rate of good outcome was 29% (n = 32/111) but was 52% (n = 13/25) in patients with baseline mRS score of 0-2 who were selected based on CT perfusion and treated with stent retrievers. On multivariate analysis, only ASPECTS (OR 2.17; 95% CI 1.28-3.67.7; p = 0.004) and baseline NIHSS score (OR 0.87; 95% CI 0.77-0.97; p = 0.013) were independently associated with good outcome. A FIV ≤16 ml demonstrated the greatest accuracy for identifying good outcomes (sensitivity 75.0%, specificity 82.6%). CONCLUSIONS: Our results are encouraging demonstrating nearly one-third of elderly patients achieving full independence at 90 days. Contemporary treatment paradigms employing optimized patient selection and modern thrombectomy technology may result in even better outcomes.

Endovascular Treatment of Acute Ischemic Stroke Due to Tandem Occlusions: Large Multicenter Series and Systematic Review.

BACKGROUND: Ischemic strokes due to tandem occlusions (TOs) have poor outcomes if they have been treated with only medical interventions. Recent trials demonstrated the effectiveness of endovascular treatment of acute ischemic stroke due to intracranial occlusions; however, most studies excluded patients with TOs. METHODS: Retrospective review of prospectively collected thrombectomy databases from 3 stroke centers between 2011 and 2015. Consecutive patients with tandem extracranial steno-occlusive carotid disease and intracranial occlusions who underwent emergent thrombectomy were selected. Angiographic and clinical outcomes were analyzed; baseline and procedural variables were included in univariate and multivariate analyses to define the independent predictors of good outcomes (90-day modified Rankin Scale ≤2). RESULTS: A total of 100 patients met the study inclusion criteria. The mean age was 64.4 ± 12.5, baseline National Institutes of Health Stroke Scale (NIHSS) 17.6 ± 5.0, time from last known well to puncture 7.3 ± 5.8 h, and Alberta Stroke Program Early CT Score (ASPECTS) 7.5 ± 1.6. Forty percent received intravenous tissue plasminogen activator. Intracranial occlusion sites included: internal carotid artery thrombus, 31%; middle cerebral artery (MCA)-M1, 53%; MCA-M2, 10%; and anterior cerebral artery, 6%. Good outcome was achieved in 42% and successful reperfusion modified thrombolysis in cerebral infarction (mTICI ≥2B) in 88% of the cases, including complete (mTICI 3) reperfusion in 40%. Severe parenchymal hematoma (PH)-2 occurred in 6% of the patients and 90-day mortality was 20%. In the multivariate analysis, younger age (OR 0.93; 95% CI 0.88-0.98; p = 0.004), lower baseline NIHSS (OR 0.84; 95% CI 0.74-0.94; p = 0.003), higher ASPECTS (OR 1.50; 95% CI 1.02-2.19; p = 0.038), and mTICI 3 reperfusion (OR 3.56; 95% CI 1.18-10.76; p = 0.024) were independent predictors of good outcome at 90 days. CONCLUSIONS: Acute endovascular treatment of tandem anterior circulation occlusions yields good outcomes and has similar outcome predictors to isolated intracranial occlusions. Given their comparable clinical behavior, these patients should be included in future trials.

Endovascular Management vs Intravenous Thrombolysis for Acute Stroke Secondary to Carotid Artery Dissection: Local Experience and Systematic Review.

BACKGROUND: Little is known regarding the endovascular management of acute ischemic stroke (AIS) related to carotid artery dissection (CAD). OBJECTIVE: To report our interventional experience in AIS from CAD and to compare it with conservative treatment of CAD with intravenous thrombolysis (IVT) via systematic review. METHODS: Retrospective analysis of consecutive high-grade steno-occlusive CAD with National Institutes of Health Stroke Scale (NIHSS) >5 and ≤12 hours of last seen normal from 2 tertiary centers. A systematic review for studies on IVT in the setting of CAD via PubMed was performed for comparison. RESULTS: Of 1112 patients treated with endovascular interventions within the study period, 21 met the inclusion criteria. Mean age was 52.0 ± 10.9 years, 76% were male, NIHSS was 17.4 ± 5.8, 52% received IVT before intervention, and 90% had tandem occlusions. Mean time from last-known-normal to puncture was 4.8 ± 2.1 hours and procedure length 1.8 ± 1.0 hours. Stents were used in 52% of cases, and reperfusion (modified Treatment in Cerebral Ischemia 2b-3) achieved in 95%. No parenchymal hemorrhages were observed and 71% achieved good outcome (90-day modified Rankin Scale 0-2). The literature review identified 8 studies concerning thrombolysis in the CAD setting fitting inclusion criteria (n = 133). Our endovascular experience compared with the pooled IVT reports indicated that, despite presenting with higher NIHSS (17 vs 14; P = .04) and experiencing a longer time to definitive therapy (287 vs 162 minutes; P < .01), patients treated intra-arterially had similar rates of symptomatic cerebral/European Cooperative Acute Stroke Study-parenchymal hematoma 2 hemorrhage (0% vs 6%; P = .43) and good outcomes (71% vs 52%; P = .05). CONCLUSION: Our study provides evidence that the endovascular management of AIS in the setting of CAD is a feasible, safe, and promising strategy.

Eligibility determination for intravenous thrombolysis based on radiology interpretation report of the head CT scan in patients with acute ischemic stroke.

OBJECTIVE: To evaluate the variability of determining eligibility for intravenous thrombolysis (IV t-PA) by a stroke team interpretation of computed tomographic (CT) scan of the head versus review of the radiology interpretation (presented in final report) in patients with acute ischemic stroke. METHODS: We compiled a database of all IV t-PA-treated ischemic stroke patients at our academic institution based on the stroke team's CT scan interpretation. The CT scan reports of 171 patients were reviewed by an independent board-certified vascular neurologist who was blinded to clinical information except that all patients were being considered for IV t-PA to determine their eligibility for thrombolysis. The reviewer's responses were then compared with the treating team's decision to identify discrepancies, and the impact of the discrepant decisions on clinical outcome including 24-hour National Institute of Health stroke Scale (NIHSS) score and discharge modified Rankin scale (mRS), symptomatic hemorrhage (sICH), and asymptomatic hemorrhage (aICH). We compared the outcomes of patients who received IV t-PA despite cautionary neuroradiologist interpretation and placebo-treated patients from NINDS t-PA study. RESULTS: The independent reviewer decided to treat with IV t-PA 123 patients (72%) after reviewing the radiology reports. The rate of NIHSS score improvement (52.0% vs. 62.5%, P = .22) was not different between patients in whom IV t-PA should or should not have been used based on radiology reports. Favorable clinical outcome defined by mRS of 0-2 at discharge (50.4% vs. 47.9%, P = .77) and in-hospital mortality (15.6% vs. 12.5%, P = .61) were similar between the 2 groups. Favorable outcome (discharge or day 7-10 mRS 0-2) was significantly higher in patients who received t-PA compared with placebo-treated patients (48% vs. 28%, P = .006). CONCLUSION: Our study demonstrates that administering IV t-PA to patients based on the stroke team's interpretation of the CT scan versus review of the radiology interpretation does not lead to significant differences in clinical outcome, aICH, or sICH.

High risk of new episode of symptomatic vasospasm in unaffected arteries in subarachnoid hemorrhage patients receiving targeted endovascular treatment for symptomatic focal vasospasm.

BACKGROUND: There is controversy whether asymptomatic vasospasm in other arteries should be concurrently treated (global treatment) in patients receiving targeted endovascular treatment [percutaneous-transluminal-angioplasty (PTA) and/or intra-arterial (IA) vasodilators] for focal symptomatic vasospasm. OBJECTIVE: To determine the rates of occurrence of new symptomatic vasospasm in previously asymptomatic arterial distributions among patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent targeted endovascular treatment for focal symptomatic vasospasm. METHODS: We identified all patients with SAH who had received targeted endovascular treatment during a 4-year period. We ascertained any new occurrence of symptomatic vasosopasm requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the same hospitalization. Blinded reviewers quantitatively graded angiographic vasospasm (<25, 26-49, ≥50 %) in all major arteries for each patient at the time of targeted treatment. RESULTS: Of the 41 patients who received targeted endovascular treatment (PTA in 41 % and vasodilators in 59 %), 11 (27 %) developed new symptomatic vasospasm in previously asymptomatic vascular distributions requiring endovascular treatment. Moderate severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment tended to predict the occurrence of new symptomatic vasospasm. The rate of death and disability at discharge [modified Rankin scale (mRS) of 3-6] was 82 % (9/11) among those who developed a new episode of symptomatic vasospasm compared with 70 % (21/30) in those who did not (P = 0.58). CONCLUSIONS: High risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global endovascular treatment during the initial targeted endovascular treatment session.

Marginal sinus fistula supplied exclusively by vertebral artery feeders.

A 54-year-old woman is reported with severe pulsatile tinnitus. Digital subtraction angiography demonstrated dural arteriovenous fistula of the marginal sinus with feeders arising exclusively from bilateral vertebral arteries. Patient underwent successful transarterial Onyx embolization with complete angiographic and clinical cure.

Endovascular balloon-assisted embolization of intracranial and cervical arteriovenous malformations using dual-lumen coaxial balloon microcatheters and Onyx: initial experience.

BACKGROUND: Ethylene vinyl alcohol copolymer (Onyx) is widely used for the embolization of arteriovenous malformations (AVMs) of the brain, head, and neck. Balloon-assisted Onyx embolization may provide additional unique advantages in the treatment of AVMs in comparison with traditional catheter-based techniques. OBJECTIVE: To report our initial experience in performing balloon-assisted AVM embolization for brain and neck AVMs with the use of the new Scepter-C and Scepter-XC coaxial dual-lumen balloon microcatheters. METHODS: Balloon-assisted transarterial embolization was performed in a series of 7 patients with AVMs (4 with brain AVMs, 1 with a dural arteriovenous fistula, and 2 with neck AVMs) by using Onyx delivered through the lumen of Scepter-C or Scepter XC coaxial balloon microcatheters. Following the initial balloon-catheter navigation into a feeding artery and the subsequent inflation of the balloon, the embolization was performed by using Onyx 18, Onyx 34, or both. RESULTS: A total of 12 embolization sessions were performed via 17 arterial feeders in these 7 patients. In 1 patient, there was an arterial perforation from the inflation of the balloon; in all others, the embolization goals were successfully achieved with no adverse events. CONCLUSION: The balloon microcatheters showed excellent navigability, and there were no problems with retrieval or with the repeated inflation and deflation of the balloons. A proximal Onyx plug, which is crucial in many AVM embolizations, was not necessary with this technique. Additionally, fluoroscopy and procedural times seemed lower with this technique compared with conventional embolization methods.

Sequential sidelong balloon remodeling technique in coil embolization of a wide-necked basilar tip aneurysm.

The use of balloon remodeling technique for coil embolization has developed into a safe alternative to stent assisted coil embolization for wide-necked aneurysms. Dual antiplatelet therapy when a stent is placed for assistance in the treatment of ruptured aneurysms is of concern. There are cases in which a single balloon seems insufficient to protect from coil herniation, like when two vessels are in the proximity of the side of the aneurysm neck. Techniques using two balloons for remodeling have been described; however, dual vascular access may be required. A case is presented in which a ruptured basilar tip wide-necked aneurysm was treated with a single balloon, using a sequential sidelong balloon remodeling technique. Complete embolization of the aneurysm was achieved maintaining patency of bilateral posterior cerebral arteries.

Value of Other Endovascular Techniques Among Patients with MERCI Device Failure during the Treatment of Acute Ischemic Stroke: What to do when MERCI fails?

BACKGROUND: The MERCI Retrieval system (Concentric Medical, Mountain View, CA) was the first FDA -approved device for mechanical thrombectomy in patients with acute ischemic stroke. It remains one of the most commonly used devices today despite its failure to restore blood flow in approximately 50% of the occlusions after technically successful deployment and retrieval. It remains unclear whether additional endovascular techniques or continued use of MERCI device can achieve recanalization post- MERCI failure. OBJECTIVE: To analyze the outcome of continued MERCI retriever use compared with other endovascular techniques after initial failure. METHODS: Failure of MERCI retriever was defined by successful deployment and retrieval of MERCI across target occlusion without recanalization in a single pass.. Pre- and post- treatment cerebral angiogram was classified using the Qureshi Grading Scale (QGS). Recanalization was defined by a reduction in ≥ 1 QGS grade between pre- and post- treatment cerebral angiogram in the Qureshi Grading Scale (QGS).We ascertained and compared the angiographic and clinical results with continued use of MERCI retriever or other endovascular techniques in patients following MERCI failure. RESULTS: A total of 40 patients (53% men) had MERCI retrieval in this cohort with a mean age (±standard deviation) of 66.8 years ± 16 years and a mean admission National Institutes of Health Stroke Scale (NIHSS) score of 16.8 ± 6.7. Of the 40 patients treated with MERCI retrieval, there were 26 patients with MERCI failure. In group 1, there were 11 patients who underwent continued MERCI use and group 2 consisted of 15 patients who underwent an alternate endovascular technique. There was no significant difference in age, risk factors, or outcomes between the groups. The rate of recanalization (82% versus 80%, p=1.0), asymptomatic intra cerebral hemorrhage (18% versus 13%, p =0.77) and favorable outcome at discharge (27% versus 20%, p =0.66) were similar amongst the two groups. CONCLUSIONS: Continued attempts using the MERCI device did not result in higher recanalization rates when compared to alternate endovascular treatment modalities following initial MERCI failure. Both techniques produced comparable rates of recanalization and favorable outcome.

Value of Other Endovascular Techniques Among Patients with MERCI Device Failure during the Treatment of Acute Ischemic Stroke: What to do when MERCI fails?

BACKGROUND: The MERCI Retrieval system (Concentric Medical, Mountain View, CA) was the first FDA -approved device for mechanical thrombectomy in patients with acute ischemic stroke. It remains one of the most commonly used devices today despite its failure to restore blood flow in approximately 50% of the occlusions after technically successful deployment and retrieval. It remains unclear whether additional endovascular techniques or continued use of MERCI device can achieve recanalization post- MERCI failure. OBJECTIVE: To analyze the outcome of continued MERCI retriever use compared to other endovascular techniques after initial failure. METHODS: Failure of MERCI retriever was defined by successful deployment and retrieval of MERCI across target occlusion without recanalization in a single pass.. Pre- and post- treatment cerebral angiogram was classified using the Qureshi Grading Scale (QGS). Recanalization was defined by a reduction in ≥ 1 grade between pre- and post- treatment cerebral angiogram in the Qureshi Grading Scale (QGS). We ascertained and compared the angiographic and clinical results with continued use of MERCI retriever and other endovascular techniques in patients with MERCI failure. RESULTS: A total of 40 patients (53% men) had MERCI retrieval in this cohort with a mean age (±standard deviation) of 66.8 years ± 16 years and a mean admission NIHSS score of 16.8 ± 6.7. Of the 40 patients treated with MERCI retrieval, there were 26 patients with MERCI failure. In group 1, there were 11 patients who underwent continued MERCI use and group 2 consisted of 15 patients who had an alternate endovascular technique. There was no significant difference in age, risk factors, or outcomes between the groups. The rate of recanalization (82% versus 80%, p=1.0), asymptomatic intra cerebral hemorrhage (18% versus 13%, p =0.77) and favorable outcome at discharge (27% versus 20%, p =0.66) were similar amongst the two groups. CONCLUSIONS: Continued attempts using the MERCI device did not result in higher recanalization rates when compared to alternate endovascular treatment modalities following initial MERCI failure. Both techniques produced comparable rates of recanalization and favorable outcome.

Is there a decreased risk of intracerebral hemorrhage and mortality in obese patients treated with intravenous thrombolysis in acute ischemic stroke?

BACKGROUND: The current guidelines do not recommend increasing the dose of intravenous recombinant tissue plasminogen activator (IV rt-PA) for ischemic stroke patients weighing >100 kg. Obese patients are therefore receiving an IV rt-PA dose <0.9 mg/kg; however, the consequences of such underdosing are unknown. Our goal was to determine the relationship between obesity and clinical outcomes among acute ischemic stroke patients receiving IV rt-PA. METHODS: Data from all patients admitted to US hospitals between 2002 and 2009 who were treated with IV thrombolysis and who had a primary discharge diagnosis of stroke were included. The effect of obesity on rates of intracerebral hemorrhage and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. RESULTS: Of the 81,579 patients with ischemic stroke treated with IV rt-PA, 5174 (6.3%) were categorized as obese. The intracerebral hemorrhage rates in obese and nonobese patients were significantly different (4.5% v 6.3%; P = .01). After adjusting for age, sex, presence of hypertension, diabetes mellitus, location/teaching status and All Patient Refined Diagnosis Related Group severity scale, there was no difference in the rates of no to minimal disability between obese and nonobese patients (odds ratio [OR] 1.0; 95% confidence interval [CI] 0.8-1.2; P = .8). Obese patients had lower odds of in-hospital mortality (OR 0.6; 95% CI 0.5-0.8; P = .001) but also more likely to be discharged with moderate to severe disability (OR 1.2; 95% CI 1.01-1.3; P = .03). CONCLUSIONS: Obese patients receiving IV rt-PA treatment for acute ischemic stroke appear to have a higher survival rate most likely related to their decreased rates of intracerebral hemorrhage.

Vessel occlusion using a single long oversized coil in vertebral artery dissection: a technical note.

Vertebral artery dissection may lead to stroke. Medical therapy is usually the first line of treatment. The endovascular approach of medically refractory vertebral artery dissection may include numerous techniques, including coil occlusion of the parent vessel. Two cases are presented of medically refractory symptomatic vertebral artery dissections in which vessel coil occlusion was successfully achieved with a single long oversized coil. There were no periprocedural complications and both patients had excellent clinical and angiographic outcome and remained asymptomatic on follow-up. The use of a single long oversized coil in vessel sacrifice has not been described previously. It represents a safe, rapid and cost effective alternative to the current existing techniques for vessel sacrifice.

National trends in utilization and outcomes of endovascular treatment of acute ischemic stroke patients in the mechanical thrombectomy era.

BACKGROUND AND PURPOSE: Because several new devices for mechanical thrombectomy have become available, the outcomes of patients undergoing endovascular treatment for acute ischemic stroke are expected to improve in the United States. We performed this analysis to evaluate trends in utilization of endovascular treatment and associated rates of death and disability among acute ischemic stroke patients over a 6-year period, including further assessment within age strata. METHODS: We obtained data for patients admitted to hospitals in the United States from 2004 to 2009 with a primary diagnosis of ischemic stroke using a large national database. We determined the rate and pattern of utilization, and associated in-hospital outcomes of endovascular treatment among ischemic stroke patients and further analyzed trends within age strata. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition and compared between 2 time periods: 2004 to 2007 (post-MERCI) and 2008 to 2009 (post-Penumbra) approvals RESULTS: Of the 3,292,842 patients admitted with ischemic stroke, 72,342 (2.2%) received intravenous thrombolytic treatment and 13 799 (0.4%) underwent endovascular treatment. There was a 6-fold increase in patients who underwent endovascular treatment (0.1% of ischemic strokes in 2004 vs 0.6% in 2009; P<0.001), with the patients aged≥85 years having the lowest rate of utilization (0.2%). The rates of intracranial hemorrhage remained unchanged throughout the 6 years. In multivariate logistic regression analysis, after adjusting for age, gender, presence of hypertension, congestive heart failure, renal failure, and secondary intracranial hemorrhages, there was no difference in the rate of minimal disability between the 2 study intervals (2004-2007 vs 2008-2009; odds ratio, 0.8; 95% confidence interval, 0.7-1.04; P=0.11). Mortality decreased while moderate to severe disability increased for patients treated during 2008 to 2009 (odds ratio, 0.7; 95% confidence interval, 0.6-0.9; P=0.007; and odds ratio, 1.4; 95% confidence interval, 1.2-1.7; P=0.0002). CONCLUSIONS: There has been a significant increase in the proportion of acute ischemic stroke patients receiving endovascular treatment over the 6 years and reduction in in-hospital mortality. Our results highlight the need to implement endovascular techniques in a balanced manner across various age groups that also results in the reduction of disability in addition to mortality.