Catheter exchange technique for the Wingspan stent: technical note.

BACKGROUND AND PURPOSE: The only Food and Drug Administration-approved implant for managing intracranial stenosis is the Wingspan stent. Modification of the standard Wingspan stent delivery procedure has not been previously reported. MATERIAL AND METHODS: Retrospective, single-patient, technical report. RESULTS: Following uneventful balloon angioplasty, a symptomatic intracranial vertebral artery stenosis was inaccessible to Wingspan stent delivery using standard procedural protocol because of poor proximal guide catheter purchase. After placing a Renegade Hi-Flo microcatheter across the stenosis, the Wingspan stent was transferred to this catheter and advanced to the lesion using a Neuroform stabilizer. Unsheathing of the stent yielded uncomplicated, precise placement of the stent with a good clinical result. CONCLUSION: The Wingspan stent transfer technique can be used successfully in the management of intracranial stenotic disease.

Smoking Cessation Strategies in Pregnancy.

Although pregnancy often motivates women to quit smoking, 20% to 25% will continue to smoke. Smoking is associated with adverse obstetric and neonatal outcomes such as placental abruption, stillbirth, preterm birth and sudden infant death syndrome, and it is therefore important to motivate women to quit during pregnancy. In this review, we explore the efficacy and evidence for safety of strategies for smoking cessation in pregnancy, including behavioural and pharmacologic therapies. The PubMed, Medline, EMBASE, and Cochrane databases (1990 to 2014) were accessed to identify relevant studies, using the search terms "smoking cessation," "pregnancy," "medicine, behavioural," "nicotine replacement products," "bupropion," and "varenicline." Studies were selected based on the levels of evidence presented by the Canadian Task Force on Preventative Health Care. Based on our review of the evidence, incentives combined with behavioural therapy appear to show the greatest promise for abstaining from smoking in the pregnant population. Nicotine replacement therapy administered in the form of gum may be better than using transdermal forms to avoid high levels of nicotine in the fetal circulation. One small trial demonstrated that bupropion is an effective aid for smoking cessation and that it does not appear to be associated with an increased risk of major congenital malformations. The currently available studies of varenicline in pregnancy are insufficient to provide evidence for the safety or efficacy of its use.

Bien que la grossesse parvienne souvent à motiver les femmes à abandonner le tabagisme, de 20 % à 25 % des femmes enceintes continuent de fumer. Le tabagisme est associé à des issues indésirables obstétricales et néonatales telles que le décollement placentaire, la mortinaissance, l'accouchement préterme et le syndrome de mort subite du nourrisson; il est donc important de motiver les femmes à cesser de fumer pendant la grossesse. Dans cette analyse, nous explorons l'efficacité des stratégies d'abandon du tabagisme (y compris les traitements comportementaux et pharmacologiques) et les données en soutenant l'innocuité pendant la grossesse. Nous avons mené des recherches dans les bases de données PubMed, Medline, EMBASE et Cochrane en vue d'en tirer les études pertinentes (1990-2014) au moyen des termes de recherche suivants : smoking cessation, pregnancy, medicine, behavioural, nicotine replacement products, bupropion et varenicline. Les études ont été sélectionnées en fonction des niveaux de résultats présentés par le Groupe d'étude canadien sur les soins de santé préventifs. Notre analyse des données probantes indique que l'offre concomitante d'incitatifs et d'une thérapie comportementale semble être la plus prometteuse pour ce qui est de l'abandon du tabagisme pendant la grossesse. Le recours à la thérapie de remplacement de la nicotine administrée sous forme de gomme pourrait être plus efficace que le recours aux formes transdermiques pour éviter l'obtention de taux élevés de nicotine dans la circulation fœtale. Un essai de faible envergure a démontré que le bupropion constitue un agent efficace pour l'abandon du tabagisme et qu'il ne semble pas être associé à un risque accru de malformations congénitales majeures. Les données qui sont issues des études actuellement disponibles s'étant penchées sur l'utilisation de varénicline pendant la grossesse ne sont pas suffisantes pour en étayer l'innocuité ou l'efficacité.

Transvenous embosurgery of a left sigmoid sinus dural arteriovenous fistula via a retrograde approach from the superior ophthalmic vein, cavernous and inferior petrosal sinuses.

The efficacy and safety of transvenous embosurgery for sigmoid sinus dural arteriovenous fistula (DAVF) using the internal jugular vein approach is well known. Embosurgery of cavernous sinus DAVF has also been described utilizing a superior ophthalmic vein approach. The first report of a sigmoid sinus DAVF endosurgical repair via a superior ophthalmic vein approach in a patient without internal jugular vein access is presented.

Resolution of trigeminal neuralgia following cerebellar AVM embolization with Onyx.

Intracranial arteriovenous malformation (AVM) is a rare cause of trigeminal neuralgia (TN). Successful resolution of AVM-related TN following embolization surgery using Onyx has not been reported. In this case report, a posterior fossa AVM was embolized in two separate, staged endovascular surgeries using Onyx. The AVM was reduced in size, and the TN resolved. The patient subsequently underwent radiosurgery for the small, residual AVM, and he has maintained an uneventful follow-up. A thorough literature review was also performed for AVM-associated TN. Fifty-nine reports of AVM-related TN have been described to date, of which only three were treated with embosurgery. None of the prior two embosurgical reports utilized Onyx, and no AVM was obliterated with embosurgery alone. TN secondary to AVM can be resolved with embosurgery utilizing Onyx; however, complete elimination of the underlying AVM requires adjuvant surgery.

Predicting acute ischemic stroke by measuring the degree of ocular gaze deviation (Prevost's sign) on CT.

BACKGROUND AND AIM: Ocular gaze deviation (OGD) is a well known clinical observation (Prevost's sign) in patients with acute cerebral ischemic stroke. Although OGD has been observed on CT in acute stroke, no investigation has quantified the degree of OGD in acute stroke. MATERIAL AND METHODS: A blinded prospective comparison was performed of two groups of adult patients who underwent CT of the brain. Group 1 comprised patients with acute hemiplegia or hemiparesis due to middle cerebral artery ischemic stroke. Group 2 included ambulatory outpatients with a history of headache but no clinical neurologic signs or cerebral pathology on CT. The CT images were cropped to only show the orbital contents. A neuroradiologist, who was blinded to the clinical data, then measured the OGD for both groups. The OGD was quantified using the axial planes of the lenses relative to the nasal midline structures, and the bilateral OGD average was calculated. Both groups were also evaluated for conjugate or disconjugate gaze. RESULTS: were analyzed using Fisher's exact test. RESULTS: 10 of 70 patients in group 1 and 15 of 46 patients in group 2 were eligible for analysis. The frequency of conjugate and disconjugate gaze was similar in the two groups (p = 0.596). An averaged OGD of >14° and an OGD >18° in either globe was predictive of the presence of acute stroke (p = 0.0166). CONCLUSION: Measurement of OGD is useful in predicting the presence of acute ischemic stroke.

Balloon test occlusion and endosurgical parent artery sacrifice for the evaluation and management of complex intracranial aneurysmal disease.

The lifetime risk of developing a cerebral aneurysm is about 5%. For some patients, aneurysms can be reasonably managed by conservative measures, including periodic clinical and imaging surveillance. However, the definitive treatment of cerebral aneurysm disease requires securing the aneurysm by surgically excluding it from the cerebrovascular circulation. Most commonly, this can be achieved by either open surgical clipping or embosurgery. Unfortunately, for a minority of patients, these interventions are inadequate because of many aneurysmal factors, such as complex anatomy, giant and wide neck aneurysmal morphology, peripheral small branch origin and skull base location. In situations like these, sacrifice of the parent artery may be preferable, especially when clinical tolerance or image based vascular reserve can be preoperatively demonstrated during temporary occlusion of the vessel. This preoperative procedure, which is known as the Balloon Test Occlusion (BTO), has several variations and technical nuances that can assist the surgeon in predicting which patients may best benefit from parent artery sacrifice (PAS). Together, BTO and PAS are invaluable tools in the management of complicated and atypical cerebral aneurysms. With regard to cerebrovascular aneurysm disease, this review will summarize the development of these procedures, condense the predictability of the numerous BTO variations and provide an overview of the currently available PAS techniques.

Catheter exchange technique for the Wingspan stent: technical note.

BACKGROUND AND PURPOSE: The only Food and Drug Administration-approved implant for managing intracranial stenosis is the Wingspan stent. Modification of the standard Wingspan stent delivery procedure has not been previously reported. MATERIAL AND METHODS: Retrospective, single-patient, technical report. RESULTS: Following uneventful balloon angioplasty, a symptomatic intracranial vertebral artery stenosis was inaccessible to Wingspan stent delivery using standard procedural protocol because of poor proximal guide catheter purchase. After placing a Renegade Hi-Flo microcatheter across the stenosis, the Wingspan stent was transferred to this catheter and advanced to the lesion using a Neuroform stabilizer. Unsheathing of the stent yielded uncomplicated, precise placement of the stent with a good clinical result. CONCLUSION: The Wingspan stent transfer technique can be used successfully in the management of intracranial stenotic disease.

Endosurgical repair of an iatrogenic facial arteriovenous fistula due to percutaneous trigeminal balloon rhizotomy.

A 56-year-old woman with right-sided trigeminal neuralgia (TN), who underwent technically uneventful percutaneous balloon rhizotomy, developed significant bilateral pulsatile tinnitus on the first post-operative day. Although the patient reported significantly improved neuralgia, auscultation revealed a right facial bruit. Magnetic resonance angiography (MRA) of the face and brain demonstrated prominent right facial and jugular venous vascularity. Catheter angiography confirmed the suspected facial arteriovenous fistula (AVF). A transarterial approach was used to explore the AVF which arose from a laceration of the right internal maxillary artery and which fistulized directly with the pterygoid venous plexus. Endosurgical repair utilizing three non-fibered platinum coils was done under conscious sedation at the same setting as the diagnostic angiogram. Angiographically, the fistula was obliterated, and the patient's bruit and tinnitus immediately resolved. Follow-up MRA at 3.5 months was normal, and, the patient had no clinical symptoms of recurrent AVF. In conclusion facial AVF can complicate percutaneous trigeminal rhizotomy. Iatrogenic facial AVF can be repaired via an endovascular approach.

Selective use of the paraophthalmic balloon test occlusion (BTO) to identify a false-negative subset of the cervical carotid BTO.

BACKGROUND: The extracranial, internal carotid artery balloon test occlusion is helpful in predicting ischemic stroke resulting from operative occlusion of the internal carotid artery. However, balloon test occlusion is falsely negative in up to 20% of patients. With selected use of the paraophthalmic internal carotid artery balloon test occlusion, our group has identified a patient subset that developed ischemia resulting from supraclinoid internal carotid artery occlusion, in spite of passing the standard balloon test occlusion. METHODS: Patient charts were reviewed for all balloon test occlusion referrals over a two-year period. Diagnostic angiography and standard cervical internal carotid artery balloon test occlusion were performed. The presence of retrograde ophthalmic blood flow was determined by angiography during cervical balloon test occlusion. Balloon test occlusion was then performed in those patients who both demonstrated retrograde ophthalmic blood flow during the cervical balloon test occlusion and those who were considered candidates for planned supraclinoid internal carotid artery sacrifice during skull base surgery. RESULTS: Ten patients were referred for carotid balloon test occlusion. One patient who refused balloon test occlusion was excluded. Two patients (2/9 or 22%) failed the initial balloon test occlusion. Two of the seven remaining patients (and one who failed balloon test occlusion) demonstrated retrograde ophthalmic arterial flow during cervical balloon test occlusion. Of the patients who passed the initial balloon test occlusion, one failed paraophthalmic carotid artery balloon test occlusion. Surgical planning in one patient (1/7 or 14%) was significantly modified because of the results of the paraophthalmic carotid artery balloon test occlusion. CONCLUSION: Paraophthalmic internal carotid artery balloon test occlusion is indicated when planning supraclinoid internal carotid artery sacrifice in patients who demonstrate retrograde ophthalmic arterial flow during uneventful cervical carotid balloon test occlusion.

Cerebrovascular angioplasty and stenting for the prevention of stroke.

Until recently, stroke preventive strategies have focused on either medical regimens aimed at antagonizing or reversing atherosclerosis, or surgical intervention for revascularization of the cerebrovascular system. However, with the advent of rapidly emerging microcatheterization techniques and technology, endovascular surgical revascularization of the brain is rapidly emerging as a powerful therapeutic modality. In particular, significant advances already have been made in revascularization of the extracranial carotid artery and many common anatomic sites of intracranial athero-occlusive disease, using special adaptations of conventional percutaneous angioplasty and stenting techniques. This paper reviews the cumulative experience with these emerging techniques, with a particular emphasis on clinical outcomes and future directions. It also reports the substantial cumulative institutional experience of the authors over the past 18 months with both extracranial carotid and intracranial artery stent-assisted carotid angioplasty.

Improvement in papilledema and visual loss after endovascular stent placement in dural sinus thrombosis.

OBJECTIVE: To report two cases of cerebral venous sinus thrombosis with papilledema and visual loss that improved after endovascular stent placement. MATERIALS AND METHODS: Retrospective case series from a tertiary ophthalmic center. RESULTS: Two cases of venous sinus occlusion treated with angioplasty and stenting are described. Both cases experienced improvement in optic disc edema and visual function following the procedures. CONCLUSION: Endovascular stent placement may relieve increased intracranial pressure and papilledema caused by cerebral sinus thrombosis and may prevent further visual loss.

Intravascular papillary endothelial hyperplasia arising within a posteroinferior cerebellar artery aneurysm: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Intravascular papillary endothelial hyperplasia (IPEH) is an atypical proliferation of endothelium that results in abnormal organization for thrombus formation. Intracranial IPEH is a rare entity and has not been reported to arise from within an intracranial aneurysm. Furthermore, the elapsed time during which acquired intracranial IPEH develops has not been previously documented. CLINICAL PRESENTATION: In this case report, a patient with facial and neck pain was noted to have an enhancing mass lesion lateral to the medulla in magnetic resonance imaging scans. Angiography revealed a vascular mass adjacent to the posteroinferior cerebellar artery. Normal magnetic resonance imaging and magnetic resonance angiographic findings had been obtained for the patient 29 months earlier. INTERVENTION: During surgery, a thrombosed, 2.5-cm, posteroinferior cerebellar artery aneurysm was resected and noted to contain florid IPEH. There has been no evidence of recurrence in 1 year of follow-up monitoring. A literature search revealed 13 cases of intracranial IPEH, in which recurrence was observed for incompletely resected lesions. CONCLUSION: IPEH can develop in a relatively short time, can present as a hypervascular mass lesion or within an intracranial aneurysm, and should be completely resected to prevent recurrence.