Chronic peripheral nerve hyperalgesia in the thoracolumbar region.

Chronic neuropathic pain presents a significant burden to health care worldwide. Its complexity and variation in presentation make therapeutic targeting a challenge in clinical practice. We present a case of chronic idiopathic peripheral neuropathy localized to a specific region in the back to highlight current understandings and available treatment options for neuropathic pain.

Catheter-Based Trans-Epidural Approach to Aspirate Cervical and Thoracic Epidural Abscesses: A Cadaveric Feasibility Study.

BACKGROUND: Approaching and aspirating cervical and high thoracic epidural abscesses through a trans-epidural route from the lumbar region access represents an alternative method for selected patients. OBJECTIVE: We determined the feasibility of catheter-based manipulation and aspiration using the trans-epidural route. MATERIAL AND METHODS: A custom designed infusion-suction catheter system that includes an outer suction catheter and inner infusion catheter in concentric relation with radio-opaque marker bands was tested in a cadaveric preparation to determine (1) the ability to place an aspiration catheter over a guidewire using a percutaneous approach within the posterior lumbar epidural space; (2) the highest vertebral level a catheter can be advanced within the epidural space; and (3) the ability to aspirate artificial purulent-like material placed in the cervical and thoracic level epidural space. RESULTS: We were able to advance two infusion-suction catheter systems from a 14G Touhy spinal needle inserted via an oblique parasagittal approach at the L2-L3 intervertebral space. The infusion-suction catheter was advanced up to the level of the cervical vertebral level of C2 within the epidural space under fluoroscopic guidance. We were able to aspirate artificial purulent-like material directly injected with a 22G Quincke spinal needle at vertebral levels C4-C5 and at vertebral levels T10-T11 by aspiration and manipulation of the outer catheter within the epidural space at levels C3-C7 and T9-L1, respectively. CONCLUSIONS: Our observations support the further exploration of a percutaneous catheter-based trans-epidural approach to treat epidural abscesses. The trans-epidural approach may be used alone or as a staged or concurrent approach with open surgical treatment.

Impact of advanced healthcare directives on treatment decisions by physicians in patients with acute stroke.

BACKGROUND: The implementation of advanced healthcare directives, prepared by almost half of the adult population in United States remains relatively under studied. We determined the impact of advanced healthcare directives on treatment decisions by multiple physicians in stroke patients. METHODS: A deidentified summary of clinical and radiological records of 28 patients with stroke was given to six stroke physicians who were not involved in the care of the patients. Each physician independently rated 28 treatment decisions per patient in the presence or absence of advanced healthcare directives 1 month apart to allow memory washout. The percentage agreement to treat/intervene per patient and proportion of treatment withheld as a group were estimated for each of the 28 treatment decision items. We also determined the interobserver reliability between the two raters (attorneys) in interpretation of six items characterizing the adequacy of documentation within the 28 advanced healthcare directives. RESULTS: The percentage agreement among physician raters for treatment decisions in 28 stroke patients was highest for treatment of hyperpyrexia (100%, 100%) and lowest for ICU monitoring duration based on family-physician considerations outside of accepted criteria within institution (68%, 69%) in presence and absence of advanced healthcare directives. The physician rater agreement in choosing "yes" was highest for "routine-complexity" treatment decisions and lowest for "moderate-complexity" treatment decisions. The choice of withholding treatment in "routine-complexity," "moderate-complexity," or "high-complexity" treatment decisions was remarkably similar among raters in presence or absence of advanced healthcare directives. The only treatment decision that showed an impact of advanced healthcare directives was ICU monitoring withheld in 32% of treatment decisions in presence of directives (compared with 8% in the absence of directives). IV medication and defibrillation for cardiac arrest was withheld in 29% (compared with 19%) of the treatment decisions in the presence of advanced healthcare directives. The two attorney raters found the description of acceptable outcome inadequate in 14 and 21 of 28 advanced healthcare directives reviewed, respectively. The overall mean kappa for agreement regarding adequacy of documentation was modest (43%) for "does the advanced healthcare directive specify which treatments the patient would choose, or refuse to receive if they were diagnosed with an acute, terminal condition?" and lowest (3%) for "description of acceptable outcome." CONCLUSIONS: We did not find any prominent differences in most "routine-complexity," "moderate-complexity," or "high-complexity" treatment decisions in patient management in the presence of advanced healthcare directives. Presence of advanced healthcare directives also did not reduce the prominent variance among physicians in treatment decisions.

Stent placement to treat positional occlusion of the vertebral artery: A report of two cases.

Positional occlusion of the vertebral artery is suspected in patients who present with posterior circulation signs or symptoms related to a specific head position. So far, the only reported treatment is surgery with the aim of relieving the position-dependent pressure that is applied to the vessel. We report on two patients who were treated successfully with stent placement.

Submaximal angioplasty and staged stenting for severe posterior circulation intracranial stenosis: a technique in evolution.

INTRODUCTION: Severe medically refractory intracranial stenosis portends a grave prognosis. Recent advances in stent technology have enabled clinicians to treat these lesions. Evidence in the coronary literature suggests that stenting without predilation angioplasty is as safe and effective as stenting immediately preceded by predilation angioplasty for the treatment of severely stenotic lesions. Because of marked differences in vessel histology and differences in the sensitivity of the cerebral and coronary vascular beds to embolic insult, direct stenting of severe intracranial stenoses may be more prone to neurological complications than a conventional or staged stenting procedure. METHODS: We reviewed our clinical experience with conventional, direct, and staged stenting for high-grade stenoses involving the posterior intracranial circulation. We also reviewed the literature and experimental data supporting the rationale for staged stenting. RESULTS: In our experience, no permanent neurological morbidity was identified in four patients treated with a staged approach. In contrast, one of three patients with conventional stenting of the basilar artery and two of four patients treated with direct basilar stenting had permanent neurological sequelae. CONCLUSION: For patients with high-grade posterior circulation intracranial stenoses involving the perforator-rich zones of the basilar artery, staged stenting may reduce procedure-related morbidity. A staged approach allows for plaque stabilization resulting from post-angioplasty fibrosis, which may protect patients from "snow-plowing," embolic shower of debris, or dissection. Further clinical, in vivo, and histological investigation is warranted.

Clinical and angiographic results of dilatation procedures for symptomatic intracranial atherosclerotic disease.

BACKGROUND AND PURPOSE: The authors determined the technical success and the clinical and angiographic results of angioplasty and/or stent placement for intracranial atherosclerotic disease (ICAD) at a tertiary-care referral hospital. METHODS: Angiographic and clinical outcomes occurring within the 1-month follow-up interval were recorded. Patients were followed up for a mean period of 20.5 +/- 9.2 months, and a neurovascular imaging study was performed in 18 of the 21 patients alive after a mean period of 19.7 +/- 9.2 months. Stroke-free survival and ipsilateral stroke-prevention rates were estimated using Kaplan Meier analyses. RESULTS: Twenty-four patients (mean age = 61.0 +/- 13.5 years; 15 were men) underwent 30 procedures for treatment of ICAD. The procedures included angioplasty (n = 18) and attempted primary stent placement (n = 14). In 2 procedures, angioplasty was performed in the same session after unsuccessful stent placement. There was immediate stenosis reduction (mean +/- SD) from 84% +/- 17% to 27% +/- 21%. The overall 1-month composite rate of major stroke, death, and major bleeding complications was 7% for the 30 procedures. Overall stroke-free survival at 36 months was estimated as 79% (95% confidence interval, 57%-91%), and the ipsilateral stroke-prevention rate was estimated to be 87% (95% confidence interval, 65%-95%). Among the 15 patients who underwent repeat angiography, restenosis requiring second intervention was observed in 1 patient. No restenosis could be identified in 3 patients who underwent computed tomographic or magnetic resonance angiography. CONCLUSION: This single-center study demonstrates the feasibility and effectiveness (for secondary stroke prevention) of angioplasty and/or stent placement for treatment of ICAD.

Outcomes in acute ischemic stroke patients without angiographically documented arterial occlusion.

BACKGROUND AND PURPOSE: Patients with acute ischemic stroke who undergo emergent cerebral angiography for consideration of intra-arterial treatment and do not have an angiographically demonstrable occlusion pose a management dilemma. The authors reviewed their experience to determine the clinical out comes of patients with ischemic stroke evaluated within 6 hours of symptom onset in whom negative angiograms were obtained. METHODS: A prospective registry was maintained for all patients (N = 56) who were considered for intra-arterial thrombolysis. Patients without angiographic arterial occlusion were not treated with thrombolytics, and data pertaining to clinical characteristics and neuroimaging findings was collected. Follow-up data were acquired through clinic visits or telephone interviews at 5.5 +/- 5.0 months (mean +/- SD), range 1 to 15 months, after onset of stroke. RESULTS: Of the 56 patients, no arterial occlusion was observed in 17 (30%) patients (mean age 65.8 +/- 13.0 years; 7 were men). The mean (+/- SD) baseline National Institute of Health stroke scale score was 10.2 +/- 7.1. Symptoms were referable to the anterior or posterior circulation in 76% and 18% of the patients, respectively; they could not be localized to either circulation in 6%. Follow-up neuroimaging studies demonstrated cerebral infarction in 12 of 14 patients. Eleven of the 17 had a favorable long-term recovery as assessed by the modified Rankin Scale (score 0 or 1). Five other patients had modified Rankin Scale scores of 3 (n = 1), 4 (n = 2), or 5 (n = 2). One patient died during the follow-up period. With regard to location of ischemic deficits, the highest rate of death or dependency was observed in patients with pontine infarction (three of four patients). CONCLUSION: Although the outcome following ischemic stroke in patients without angiographically documented occlusion appears to be better than that reported for patients with angiographically documented occlusion, death or disability is observed in at least one third of the patients. There fore, acute ischemic stroke in the absence of angiographic occlusion is not entirely a "benign" entity and can be particularly devastating when the brainstem is involved.

Emergency stent placement for symptomatic acute carotid artery occlusion after endarterectomy. Case report.

The authors report a case of emergency carotid artery (CA) stent placement for a symptomatic acute CA occlusion following carotid endarterectomy (CEA). This 43-year-old man underwent a right-sided CEA for an asymptomatic 80% CA stenosis detected using duplex ultrasound testing. The patient experienced hypotension and possibly a myocardial infarction intraoperatively and a left hemiplegia immediately postoperatively. He was referred to the authors' institution for consideration of emergency coronary intervention and evaluation of stroke. A computerized tomography scan of the head demonstrated subtle early ischemic changes in the right posterior parietal region. Cerebral angiography revealed occlusion of the right common CA (CCA) at the CA bifurcation. Two coronary stents (Magic Wall; Boston Scientific Scimed, Maple Grove, MN) were placed in tandem in the right CCA and internal CA (ICA), overlapping at the proximal cervical ICA. Complete recanalization of the CA was achieved, and the patient made a clinically significant recovery. Diagnostic angiography can provide important information about CA and intracranial circulation that will aid in the evaluation of postoperative stroke after CEA. Stent placement should be considered as an alternative method of treatment for acute CA occlusion or dissection following CEA.

Reocclusion of recanalized arteries during intra-arterial thrombolysis for acute ischemic stroke.

BACKGROUND AND PURPOSE: Early reocclusion of recanalized arteries has been observed after thrombolysis for acute coronary occlusion and has been attributed to platelet activation after exposure to thrombolytic agents. We conducted a retrospective study to determine the rate of reocclusion during intra-arterial thrombolysis for acute ischemic stroke and the effect of reocclusion on functional outcome. METHODS: Patients treated for acute ischemic stroke at our center between September 2000 and May 2002 received a maximum total dose of 4 U of reteplase intra-arterially in 1-U increments via superselective catheterization. Pharmacologic thrombolysis was supplemented by mechanical thrombolysis with balloon angioplasty or snare manipulation at the occlusion site. Angiography was performed after each unit of reteplase or mechanical maneuver, and the images were interpreted by a blinded reviewer. Reocclusion was defined as partial or complete initial recanalization with occlusion recurring at the same site as documented by angiography during the endovascular treatment. Reocclusions were treated by further pharmacologic and/or mechanical thrombolysis according to the discretion of the treating physician. Clinical evaluations were performed before and 24 hr, 7 to 10 days, and 1 to 3 months after treatment. RESULTS: Forty-six consecutive patients underwent intra-arterial thrombolysis. Reocclusion was observed in eight (17%). Among these patients, initial sites of occlusion were in the following arteries: intracranial internal carotid artery (n = 2), M1 segment of the middle cerebral artery (n = 3), M1 and M2 segments of the middle cerebral artery (n = 2), and basilar artery (n = 1). The mean initial National Institutes of Health Scale score for these eight patients was 23.3 +/- 6.2; mean time from symptom onset to treatment was 4.4 +/- 1.2 hr. The reocclusions were treated by using additional doses of reteplase alone (n = 1), reteplase with snare maneuver and/or angioplasty (n = 5), reteplase with angioplasty or snare and then stent placement (n = 1), and angioplasty with stent placement (n = 1). The reocclusions resolved in six of eight patients after further treatment. Six patients died and two survived but were severely disabled at 1 month (modified Rankin Scale scores of 4 and 5, respectively). Independent functional outcome scores (modified Rankin Scale scores of 0-2) were significantly lower among patients with angiographically shown reocclusion than in those without (0 of 8 versus 17 of 38, P =.02). CONCLUSION: Reocclusion occurs relatively frequently during intra-arterial thrombolysis for ischemic stroke and seems to be associated with poor clinical outcomes.

Safety of high-dose intravenous eptifibatide as an adjunct to internal carotid artery angioplasty and stent placement: a prospective registry.

OBJECTIVE: Eptifibatide, a competitive platelet glycoprotein IIb-IIIa receptor inhibitor with high selectivity for platelet glycoprotein IIb-IIIa receptors and a short half-life, has been shown to reduce the risk of ischemic events associated with coronary interventions, particularly when used in high doses. However, its role in conjunction with neurointerventional procedures needs to be determined. We report the results of an open-label prospective registry to evaluate the safety (in terms of avoiding hemorrhagic complications) and effectiveness (in terms of preventing ischemic complications such as stroke) of administering high-dose eptifibatide during internal carotid artery angioplasty and stent placement (CAS) for extracranial carotid artery stenosis. METHODS: After femoral artery access was established and intravenous heparin (30 U/kg bolus) was administered, each patient was administered intravenous eptifibatide (two 180-microg/kg single-dose boluses before CAS, then a 2.0-microg/kg/min infusion for 20-24 hours thereafter). The primary end point was the 30-day composite occurrence of death, cerebral infarction, and unplanned or urgent endovascular or surgical intervention. The primary safety end point was bleeding, for which complications were classified according to the Thrombolysis in Myocardial Infarction scheme as major (hemoglobin decrease of more than 5 g/dl), minor (hemoglobin decrease of 3-5 g/dl), or insignificant. Platelet aggregation was measured in 13 consecutive patients with a rapid platelet-function analyzer. RESULTS: Twenty-six patients (mean age, 68.1 +/- 9.4 yr; 16 men) underwent treatment. The infusion and the CAS procedure were discontinued in one patient who developed angioneurotic edema after being administered intravenous heparin and the first bolus dose of eptifibatide. Among the 25 patients who underwent the procedure, no intracerebral hemorrhages and one minor ischemic stroke occurred during the 1-month follow-up period. The minor stroke was observed on postprocedure Day 7 in a patient for whom antiplatelet therapy was discontinued before a coronary artery bypass graft operation was performed. Another patient was discharged after an uncomplicated hospitalization but died as a result of urinary sepsis 12 days after CAS. One episode of major bleeding from the femoral insertion site required surgical repair and blood transfusions. Minor bleeding occurred in one patient. Platelet aggregation measurements obtained in 13 patients revealed a high degree (mean, 96%; range, 86-100%) of platelet inhibition after the administration of the second bolus dose of intravenous eptifibatide. CONCLUSION: High-dose eptifibatide administered as an adjunct to CAS seems to be safe. Further studies are required to analyze its effectiveness and role in neurointerventional procedures.

Evolution of neuroendovascular intervention: a review of advancement in device technology.

Neuroendovascular surgery is a rapidly evolving field. Each year, numerous improvements are made in the endovascular surgeon's armamentarium. This evolution in technology, which is occurring at a dizzying pace, addresses many of the current limitations of neuroendovascular approaches. The potential to improve the outcomes of our patients is tremendous, particularly because one of the most common and most devastating neurological disorders, ischemic stroke, remains largely untreated. This article presents several of the new technologies that are currently being investigated or are under development and have the potential to lead to major advances in endovascular approaches for the treatment of intracranial and extracranial diseases.

Effect of endovascular treatment on headaches in patients with unruptured intracranial aneurysms.

BACKGROUND: Patients with unruptured intracranial aneurysms often present with headaches. OBJECTIVE: To determine the effect of endovascular treatment on the character and frequency of headaches in patients with unruptured intracranial aneurysms. METHODS: We reviewed the medical records of all patients who underwent endovascular treatment for unruptured intracranial aneurysms within a 9.5-year period. These patients were mailed a standard questionnaire in which they were asked about the frequency and character of any headache experienced before or after (or both) endovascular treatment. They were also asked to grade improvement or worsening of headaches after the procedure as mild (activities of daily living were not affected), moderate (activities of daily living were affected), or significant (the change resulted in an ability to perform new activities of daily living or an inability to perform previous activities of daily living). RESULTS: Forty-seven patients with unruptured aneurysms who underwent Guglielmi detachable coil embolization responded to the questionnaire. Of these, 32 patients (mean age, 52.7 years [SD, 13.4]; 22 were women) had experienced headaches before the procedure. Nineteen patients (59%) reported improvement in severity of headaches after embolization. Improvement was graded as significant by 7 patients, moderate by 8, and mild by 4. Two patients (6%) reported worsening severity of headaches graded as moderate. Five of 15 patients without headaches before embolization reported onset of mild (n = 4) or severe (n = 1) headaches after treatment. CONCLUSION: Guglielmi detachable coil embolization of unruptured intracranial aneurysms was associated with reduction in severity of headaches in the majority of patients who had experienced preprocedural headaches.

Comparison of periprocedure complications resulting from direct stent placement compared with those due to conventional and staged stent placement in the basilar artery.

OBJECT: Medically refractory, symptomatic atherosclerotic disease of the basilar artery (BA) portends a poor prognosis. Studies have shown morbidity rates following placement of stents in these lesions to be quite variable, ranging from 0 to 30%. The authors review their experience with BA stent placement for severe atherosclerotic disease to determine whether an increase in neurological morbidity is associated with direct stent placement (that performed without predilation angioplasty) compared with conventional stent placement (that performed immediately after predilation angioplasty) or staged stent placement (angioplasty followed > or = 1 month later by stent placement with or without repeated angioplasty). METHODS: The authors retrospectively reviewed the medical records from a consecutive series of 10 patients who underwent stent placement for medically refractory, symptomatic atherosclerotic disease of the BA between February 1999 and November 2002. Patient records were analyzed for symptoms at presentation, percentage of angiographically visible stenosis, devices used, procedure-related morbidity, and clinical and radiographic outcomes. Patients with symptomatic intracranial vertebral artery stenosis but without concomitant severe (> 50%) BA stenosis were excluded from the study. Four patients were treated with direct stent placement, three with a staged procedure (these were included in a previous publication), and three with conventional stent placement. In the group treated with direct stent placement, a dense quadriparesis developed in two patients after the procedure. Computerized tomography or magnetic resonance imaging revealed infarction of the ventral pons in these patients. In the staged stent placement group, no permanent neurological complications occurred after the procedure and, in the conventional stent placement group, one of three patients experienced a neurological complication involving homonymous hemianopsia. CONCLUSIONS: Direct stent placement in the BA is associated with a relatively high complication rate, compared with a staged procedure. Complications may result from an embolic shower following disruption of atheromatous plaque debris attained using high-profile devices such as stents, as demonstrated by the postoperative imaging appearance of acute pontine infarctions. Additionally, displacement of debris by the stent into the ostia (snowplowing) of small brainstem perforating vessels may be responsible for the complications noted. Although direct stent placement in peripheral and coronary vessels has been shown to be safe, the authors suggest that direct stent placement in the BA should be avoided to minimize the risk of periprocedure morbidity.

Transradial stenting of the cervical internal carotid artery: technical case report.

OBJECTIVE AND IMPORTANCE: We describe a case of endoluminal stent placement for a cervical internal carotid artery stenosis in which percutaneous access was obtained via the radial artery. CLINICAL PRESENTATION: A 69-year-old man with known disease of the carotid, peripheral, and coronary arteries as well as chronic obstructive pulmonary disease presented for endoluminal revascularization of a severe, progressive right internal carotid artery stenosis. TECHNIQUE: Transfemoral access was complicated by the previous placement of a synthetic graft as the result of a previous right-to-left iliofemoral artery bypass procedure and an aortoiliac occlusion. A transradial approach was successfully attempted, and a Precise stent (Cordis Endovascular, Miami Lakes, FL) was successfully placed through a 6-French guide sheath. CONCLUSION: The transradial approach is becoming an increasingly viable alternative route for stent placement in patients with contraindicated or complicated femoral access routes. As devices become increasingly more pliable and smaller, the transradial route will be used with increasing frequency in this select patient population for stenting of both the cervical and intracranial circulation.

Intracranial stent placement for the treatment of a carotid-cavernous fistula associated with intracranial angioplasty. Case report.

The authors report a case of an iatrogenic carotid-cavernous fistula (CCF) associated with intracranial angioplasty. Angioplasty was performed using a 3 x 10-mm Open Sail coronary balloon in a patient with high-grade stenosis of the left cavernous internal carotid artery (ICA). After angioplasty, a perforation developed in the cavernous ICA, resulting in a CCF. A 3.5 x 9-mm S670 coronary stent was used to treat the fistula. To the authors' knowledge, this is the first reported case in which a CCF developed after angioplasty was performed using a coronary balloon. Long-term angiographic and clinical evaluation is needed to test the suitability and durability of intracranial angioplasty and stent placement in the treatment of symptomatic intracranial stenosis.

Apoptosis as a form of cell death in intracerebral hemorrhage.

OBJECTIVE: The goals of this study were to identify and quantify the presence of programmed cell death (apoptosis) in intracerebral hemorrhage (ICH) among human subjects. Recent evidence from laboratory models suggests that cell death in the perihematoma region may involve apoptosis. METHODS: Retrospective clinical and histological analyses were performed for patients with spontaneous ICH who underwent surgical evacuation. Quantification of apoptotic cells was performed in sections obtained from the perihematoma region from 12 patients with ICH and stained with the terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling method. Necrosis was identified on the basis of morphological criteria, using hematoxylin and eosin staining. RESULTS: Evidence of apoptosis was present in surgical specimens obtained from 10 of the 12 patients. The mean number of apoptotic cells in the perihematoma region in each patient specimen was 38% (range, 0-90%). For five patients, more than one-half of the total cells observed were apoptotic. Apoptosis was observed in specimens obtained within 1 day, 2 days, and 5 days after the onset of symptoms. No terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling-positive cells were observed in specimens from the two patients with cerebellar hematomas. The mean proportion of necrotic cells in the perihematoma region in each patient specimen was 25% (range, 0-100%). There was a prominent excess of apoptotic cells, in comparison with necrotic cells, for 6 of the 12 patients who underwent hematoma evacuation. For five other patients, similar proportions of apoptotic and necrotic cells were observed. Necrosis was the predominant finding for only one patient, who underwent late surgical evacuation on Day 5. CONCLUSION: These observations suggest that apoptosis represents a prominent form of cell death associated with ICH in the perihematoma region. Further studies are required to define the mediators of apoptosis in ICH.

Brainstem infarction after delayed thrombosis of a stented vertebral artery fusiform aneurysm: case report.

OBJECTIVE AND IMPORTANCE: Recent technological advances have provided clinicians with stents that can be navigated throughout the tortuous proximal vessels of the posterior intracranial circulation. There have been few reports of fusiform and wide-necked aneurysms treated with stents. Of the known risks involved in stent placement in the intracranial circulation, delayed stent thrombosis has not been well described. CLINICAL PRESENTATION: A 34-year-old man who experienced the sudden onset of a severe headache with increasing lethargy was found on computed tomographic imaging to have a subarachnoid hemorrhage. Angiography revealed a left vertebral artery fusiform aneurysm that incorporated the posteroinferior cerebellar artery origin. INTERVENTION: A low-porosity Magic Wallstent (Boston Scientific, Natick, MA) was placed in the left vertebral artery across the aneurysm and the origin of the posteroinferior cerebellar artery. Angiography performed 9 days later revealed significant reduction in filling of the aneurysm. The patient returned 3 months after stent placement with severe neurological deterioration from a brainstem infarction caused by complete thrombotic occlusion of the left vertebral artery at the stented segment of the vessel. CONCLUSION: Stenting of fusiform aneurysms has provided an alternative to surgical clipping or parent vessel reconstruction. With the increasing frequency of intracranial stent placement for various cerebrovascular disease entities, we must become aware of potential complications associated with these procedures. Such awareness may influence decision-making processes regarding treatment and follow-up care.

Aggressive mechanical clot disruption and low-dose intra-arterial third-generation thrombolytic agent for ischemic stroke: a prospective study.

OBJECTIVE: We prospectively evaluated the safety and effectiveness of aggressive mechanical disruption of clot in conjunction with intra-arterial administration of a low-dose third-generation thrombolytic agent (reteplase) to treat ischemic stroke in patients who were considered poor candidates for intravenous alteplase therapy or who failed to improve after intravenous thrombolysis. Mechanical clot disruption was used if low-dose pharmacological thrombolysis was ineffective. This strategy was adopted to increase the recanalization rate without increasing the risk of intracerebral hemorrhage. METHODS: Patients were considered poor candidates for intravenous therapy because of severity of neurological deficits, interval from symptom onset to presentation of at least 3 hours, or recent major surgery. We administered a maximum total dose of 4 U of reteplase intra-arterially in 1-U increments via superselective catheterization. After the initial doses were administered, we performed mechanical angioplasty (for proximal occlusion) or snare manipulation (for distal occlusion) at the occlusion site if recanalization had not occurred. The remaining doses of thrombolytics were subsequently administered if required for further recanalization. Angiographic responses were graded using modified Thrombolysis in Myocardial Infarction (TIMI) criteria. Clinical evaluations were performed before and 24 hours, 7 to 10 days, and 1 to 3 months after treatment. RESULTS: Nineteen consecutive patients were treated (mean age, 64.3 +/- 16.2 yr; 10 were men). Initial National Institutes of Health Stroke Scale scores ranged from 11 to 42. Time from onset to treatment ranged from 1 to 9 hours. Occlusion sites were in the following arteries: cervical internal carotid (n = 7), intracranial internal carotid (n = 1), middle cerebral (n = 9), and basilar (n = 2). Of the 19 patients, thrombolysis alone was used in 5 patients, angioplasty was performed in 11 patients, and snare maneuvers were used in 5 patients. Complete restoration of blood flow (modified TIMI Grade 4) was observed in 12 patients, near-complete restoration of flow (modified TIMI Grade 3) in 4 patients, minimal response (modified TIMI Grade 1) in 1 patient, and no response in 2 patients (modified TIMI Grade 0). Neurological improvement at 24 hours (decline of at least 4 points in National Institutes of Health Stroke Scale score) was observed in seven patients. Five other patients experienced further improvement in National Institutes of Health Stroke Scale score at 7 to 10 days. No vessel rupture, dissection, or symptomatic intracranial hemorrhages were observed. At the time of follow-up evaluation, 7 of 19 patients were functionally independent. CONCLUSION: A high rate of recanalization and clinical improvement can be observed in patients with ischemic stroke using low-dose thrombolytic agents with adjunctive mechanical disruption of clot. Moreover, this strategy may reduce the risk of intracerebral hemorrhage observed with thrombolytics.

Should interventional cardiologists treat ischemic strokes? A global perspective.

Stroke is the third leading cause of death and the leading cause of severe neurological disability in our nation. The stroke death rate has the potential to reach epidemic proportions as the elderly segment of the population continues to rise. There is an insufficient number of trained physicians to supply the care for this patient population. The logical source for qualified physicians to care for these patients is the interventional cardiologist. We review the recent intraarterial therapy trials and detail the training necessary to allow interventional cardiologists to treat ischemic strokes.

Transradial cerebral angiography: an alternative route.

INTRODUCTION: The transradial approach has been well described for arteriography of the coronary vessels. To assess the safety and success rate of the transradial approach for three-vessel or four-vessel diagnostic cerebral arteriography, we reviewed the experience at our institution and compared our complication rates with those found in the literature for transfemoral cerebral angiography and transradial coronary angiography. METHODS: We reviewed the electronic medical records of 129 consecutive patients in whom 132 cerebral angiographic studies were performed by use of a transradial approach between December 1999 and June 2001. A total of 54 selective catheterizations were performed, of which 39 were of the vertebral artery, 11 of the internal carotid artery, and 4 of the external carotid artery. Records were reviewed for periprocedural and delayed complications, indications for diagnostic angiography, and requirement of conversion to a femoral approach. Records were reviewed prospectively for the first 55 procedures and retrospectively for the next 77 procedures. RESULTS: The mean time to initial clinical follow-up was 1.5 months (median, 0.5 mo). The combined rate of periprocedural and delayed complications was 9%, and there were no major complications. Minor periprocedural complications included transient radial artery spasm (four patients), failure to access the brachial artery (two patients), severe pain (one patient), skin desquamation (one patient), and hematoma (one patient). There were no major complications. At the time of follow-up evaluation, these patients were without deficits related to cannulation of the radial artery. CONCLUSION: The transradial approach for cerebral angiography is a safe alternative to the transfemoral route. After transradial cerebral angiography, patients require a shorter observation period and are not restricted to bed rest. As technological developments generate smaller, more pliable endovascular surgical devices, future endovascular surgery may be performed transradially.