National trends in the endovascular and surgical treatment of idiopathic intracranial hypertension.

BACKGROUND: The pattern of surgical treatments for Idiopathic Intracranial Hypertension (IIH) in the United States is not well-studied, specifically the trend of utilizing endovascular venous stenting (EVS) as an emerging technique. METHODS: In this cross-sectional study, we aimed to explore the national trend of utilizing different procedures for the treatment of IIH including EVS, Optic Nerve Sheath Fenestration (ONSF), and CSF Shunting, with a focus on novel endovascular procedures. Moreover, we explored rates of 90-day readmission and length of hospital stay following different procedures, besides the effects of sociodemographic and clinical parameters on procedure choice. RESULTS: 36,437 IIH patients were identified from records between 2010 and 2018. Those in the EVS group were 29 years old on average, and 93.4 % were female. Large academic hospital setting was independently associated with higher EVS utilization, while other factors were not predictive of procedure choice. The proportion of EVS use in IIH hospitalizations increased significantly from 2010 to 2018 (P < 0.001), while there was a relative decline in the frequency of shunting procedures (P = 0.001), with ONSF utilization remaining stable (P = 0.39). The rate of 90-day readmission and length of hospital stay were considerably lower following EVS compared to other procedures (Ps < 0.001). CONCLUSION: This study presents novel population-level data on national trends in the frequency and outcome of EVS for IIH therapy. EVS was associated with shorter length of hospital stays and fewer readmission rates. In addition, a continuous increase in venous stenting compared to other procedures suggests an increasing role for endovascular therapies in IIH.

Prospective Observational Cohort Study of Tenecteplase Versus Alteplase in Routine Clinical Practice.

BACKGROUND: A 10-hospital regional network transitioned to tenecteplase as the standard of care stroke thrombolytic in September 2019 because of potential workflow advantages and reported noninferior clinical outcomes relative to alteplase in meta-analyses of randomized trials. We assessed whether tenecteplase use in routine clinical practice reduced thrombolytic workflow times with noninferior clinical outcomes. METHODS: We designed a prospective registry-based observational, sequential cohort comparison of tenecteplase- (n=234) to alteplase-treated (n=354) stroke patients. We hypothesized: (1) an increase in the proportion of patients meeting target times for target door-to-needle time and transfer door-in-door-out time, and (2) noninferior favorable (discharge to home with independent ambulation) and unfavorable (symptomatic intracranial hemorrhage, in-hospital mortality or discharge to hospice) in the tenecteplase group. Total hospital cost associated with each treatment was also compared. RESULTS: Target door-to-needle time within 45 minutes for all patients was superior for tenecteplase, 41% versus 29%; adjusted odds ratio, 1.85 (95% CI, 1.27-2.71); P=0.001; 58% versus 41% by Get With The Guidelines criteria. Target door-in-door-out time within 90 minutes was superior for tenecteplase 37% (15/43) versus 14% (9/65); adjusted odds ratio, 3.62 (95% CI, 1.30-10.74); P=0.02. Favorable outcome for tenecteplase fell within the 6.5% noninferiority margin; adjusted odds ratio, 1.26 (95% CI, 0.89-1.80). Unfavorable outcome was less for tenecteplase, 7.3% versus 11.9%, adjusted odds ratio, 0.77 (95% CI, 0.42-1.37) but did not fall within the prespecified 1% noninferior boundary. Net benefit (%favorable-%unfavorable) was greater for the tenecteplase sample: 37% versus 27%. P=0.02. Median cost per hospital encounter was less for tenecteplase cases ($13 382 versus $15 841; P<0.001). CONCLUSIONS: Switching to tenecteplase in routine clinical practice in a 10-hospital network was associated with shorter door-to-needle time and door-in-door-out times, noninferior favorable clinical outcomes at discharge, and reduced hospital costs. Evaluation in larger, multicenter cohorts is recommended to determine if these observations generalize.

Patient Characteristics and Outcomes Associated with Decline in Stroke Volumes During the Early COVID-19 Pandemic.

BACKGROUND AND PURPOSE: Delayed evaluation of stroke may contribute to COVID-19 pandemic-related morbidity and mortality. This study evaluated patient characteristics, process measures and outcomes associated with the decline in stroke presentation during the early pandemic. METHODS: Volumes of stroke presentations, intravenous thrombolytic administrations, and mechanical thrombectomies from 52 hospitals from January 1-June 30, 2020 were analyzed with piecewise linear regression and linear spline models. Univariate analysis compared pandemic (case) and pre-pandemic (control) groups defined in relation to the nadir of daily strokes during the study period. Significantly different patient characteristics were further evaluated with logistic regression, and significantly different process measures and outcomes were re-analyzed after propensity score matching. RESULTS: Analysis of 7,389 patients found daily stroke volumes decreased 0.91/day from March 12-26 (p < 0.0001), reaching a nadir 35.0% less than expected, and increased 0.15 strokes/day from March 27-June 23, 2020 (p < 0.0001). Intravenous thrombolytic administrations decreased 3.3/week from February 19-March 31 (p = 0.0023), reaching a nadir 33.4% less than expected, and increased 1.4 administrations/week from April 1-June 23 (p < 0.0001). Mechanical thrombectomy volumes decreased by 1.5/week from February 19-March 31, 2020 (p = 0.0039), reaching a nadir 11.3% less than expected. The pandemic group was more likely to ambulate independently at baseline (p = 0.02, OR = 1.60, 95% CI = 1.08-2.42), and less likely to present with mild stroke symptoms (NIH Stroke Scale ≤ 5; p = 0.04, OR = 1.01, 95% CI = 1.00-1.02). Process measures and outcomes of each group did not differ, including door-to-needle time, door-to-puncture time, and successful mechanical thrombectomy rate. CONCLUSION: Stroke presentations and acute interventions decreased during the early COVID-19 pandemic, at least in part due to patients with lower baseline functional status and milder symptoms not seeking medical care. Public health messaging and initiatives should target these populations.

Endovascular retrieval of a prematurely deployed covered stent.

Several techniques have been reported to address different endovascular device failures. We report the case of a premature deployment of a covered balloon mounted stent during endovascular repair of a post-traumatic carotid-cavernous fistula (CCF). A 50-year-old male suffered a fall resulting in loss of consciousness and multiple facial fractures. Five weeks later, he developed decreased left visual acuity, proptosis, chemosis, limited eye movements and cranial/orbit bruit. Cerebral angiography demonstrated a direct left CCF and endovascular repair with a 5.0 mm × 19 mm covered stent was planned. Once in the lacerum segment, increased resistance was encountered and the stent was withdrawn resulting in premature deployment. A 3 mm × 9 mm balloon was advanced over an exchange length microwire and through the stent lumen. Once distal to the stent, the balloon was inflated and slowly pulled back in contact with the stent. All devices were successfully withdrawn as a unit. The use of a balloon to retrieve a prematurely deployed balloon mounted stent is a potential rescue option if leaving the stent in situ carries risks.

Aortic arch calcification, procedural times, and outcomes of endovascular treatment in patients with acute ischemic stroke.

OBJECTIVE: To determine the frequency of aortic arch calcification and it's relationship with procedural times, angiographic recanalization, and discharge outcomes in acute ischemic stroke patients undergoing endovascular treatment. METHODS: The thoracic component of computed tomographic (CT) angiogram were reviewed by an independent reviewer to determine presence of any calcification; and the severity of calcification was graded as follows: mild, single small calcifications; moderate, multiple small calcifications; or severe, one or more large calcifications. RESULTS: Aortic arch calcification was present in 120 (62.4%) of 188 patients and severity was graded as mild (n=24), moderate (n=44), and severe (n=52). Compared with patients without calcification, the mean intracranial access time (minutes ± SD) was similar among patients with aortic arch calcification (70 ± 31 versus 64 ± 31, p=0.9). The mean time intracranial access time increased with increasing severity of aortic arch calcification (61±27, 67±29, and 74±34, p=0.3). Patients with aortic arch calcification had similar rates of complete or partial recanalization [85 (71%) versus 50 (76%)], p=0.6) but lower rates of favorable outcomes [modified Rankin scale 0-2] at discharge 27 (22%) versus 26 (39%), p=0.02). CONCLUSIONS: A high proportion of acute ischemic stroke patients have aortic arch calcification which is associated with lower rates of favorable outcome following endovascular treatment. ABBREVIATIONS: SDstandard deviationICHintracerebral hemorrhageNIHSSNational Institutes of Health Stroke ScaleTIAtransient ischemic attackICHintracerebral hemorrhagemRSmodified Rankin scale.

Pattern of informed consent acquisition in patients undergoing emergent endovascular treatment for acute ischemic stroke.

BACKGROUND: Telephone consent and two physician consents based on medical necessity are alternate strategies for time sensitive medical decisions but are not uniformly accepted for clinical practice or recruitment into clinical trials. We determined the rate of and associated outcomes with alternate consenting strategies in consecutive acute ischemic stroke patients receiving emergent endovascular treatment. METHODS: We divided patients into those treated based on in-person consent and those based on alternate strategies. We identified clinical and procedural differences and differences in hospital outcomes: symptomatic ICH and favorable outcome (defined by modified Rankin Scale of 0-2 at discharge) based on consenting methodology. RESULTS: Of a total of 159 patients treated, 119 were treated based on in-person consent (by the patient in 27 and legally authorized representative in 92 procedures). Another 40 patients were treated using alternate strategies (20 telephone consents and 20 two physician consents based on medical necessity). There was no difference in the mean ages and proportion of men among the two groups based on consenting methodology. There was a significantly greater time interval incurred between CT scan and initiation of endovascular procedure in those in whom in-person consent was obtained (117 ± 65 min versus 101 ± 45 min, p = 0.01). There was no significant difference in rates of ICH (9% versus 8%, p = 0.9), or favorable outcome at discharge (28% versus 30%, p = 0.8). CONCLUSIONS: Consent through alternate strategies does not adversely affect procedural characteristics or outcome of patients and may be more time efficient than in-person consenting process.

Endovascular treatment for acute ischemic stroke patients: implications and interpretation of IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials: A report from the Working Group of International Congress of Interventional Neurology.

OBJECTIVE: The results of Interventional Management of Stroke (IMS) III, Magnetic Resonance and REcanalization of Stroke Clots Using Embolectomy (MR RESCUE), and SYNTHESIS EXPANSION trials are expected to affect the practice of endovascular treatment for acute ischemic stroke. The purpose of this report is to review the components of the designs and methods of these trials and to describe the influence of those components on the interpretation of trial results. METHODS: A critical review of trial design and conduct of IMS III, MR RESCUE, and SYNTHESIS EXPANSION is performed with emphasis on patient selection, shortcomings in procedural aspects, and methodology of data ascertainment and analysis. The influence of each component is estimated based on published literature including multicenter clinical trials reporting on endovascular treatment for acute ischemic stroke and myocardial infarction. RESULTS: We critically examined the time interval between symptom onset and treatment and rates of angiographic recanalization to differentiate between "endovascular treatment" and "parameter optimized endovascular treatment" as it relates to the IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials. All the three trials failed to effectively test "parameter optimized endovascular treatment" due to the delay between symptom onset and treatment and less than optimal rates of recanalization. In all the three trials, the magnitude of benefit with endovascular treatment required to reject the null hypothesis was larger than could be expected based on previous studies. The IMS III and SYNTHESIS EXPANSION trials demonstrated that rates of symptomatic intracerebral hemorrhages subsequent to treatment are similar between IV thrombolytics and endovascular treatment in matched acute ischemic stroke patients. The trials also indirectly validated the superiority/equivalence of IV thrombolytics (compared with endovascular treatment) in patients with minor neurological deficits and those without large vessel occlusion on computed tomographic/magnetic resonance angiography. CONCLUSIONS: The results do not support a large magnitude benefit of endovascular treatment in subjects randomized in all the three trials. The possibility that benefits of a smaller magnitude exist in certain patient populations cannot be excluded. Large magnitude benefits can be expected with implementation of "parameter optimized endovascular treatment" in patients with ischemic stroke who are candidates for IV thrombolytics.

"No turn back approach" to reduce treatment time for endovascular treatment of acute ischemic stroke.

BACKGROUND: A delay in endovascular treatment is less likely if acute ischemic stroke patients proceed from emergency department (ED) to computed tomographic (CT) scanner and directly to angiographic suite (no turn back approach). We determined the feasibility of the "no turn back approach" and its effect on treatment times and patient outcomes. METHODS: The primary outcomes were procedures performed with a time interval: (1) between ED arrival and microcatheter placement of less than 120 minutes and (2) between CT scan acquisition and microcatheter placement of less than 90 minutes. We determined the effect of the no turn back approach on favorable outcome at discharge. RESULTS: There was a significantly higher rate of CT scan acquisition and microcatheter placement time of less than 90 minutes in patients in whom no turn back approach was used (57.6% versus 31.6%, P = .0007). There was a significantly higher rate of ED arrival to microcatheter placement time of less than 120 minutes in patients in whom no turn back approach was used (31.8% versus 13.7%, P = .004). In the exploratory analysis, there was a trend toward higher rate of favorable outcomes (odds ratio 1.6, 95% confidence interval .9-2.8, P = .07) among those treated with no turn back approach after adjusting for age, admission National Institutes of Health Stroke Scale score strata, congestive heart failure, and diabetes mellitus. CONCLUSIONS: The no turn back approach appeared to be feasible and reduced the time interval between ED arrival and microcatheter placement in acute ischemic stroke patients undergoing endovascular 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.

Safety and effectiveness of endovascular treatment after 6 hours of symptom onset in patients with anterior circulation ischemic stroke: a matched case control study.

BACKGROUND: Endovascular treatment within 6 hours of symptom onset appears to be beneficial in carefully selected patients with ischemic stroke. It is unclear whether endovascular treatment beyond 6 hours of symptom onset is safe and efficacious. METHODS: Over a 6-year period, 52 patients with acute ischemic stroke in the anterior circulation underwent emergent endovascular thrombolytic infusion and mechanical thrombectomy after 6 hours of symptom onset at 3 institutions. Their outcomes were compared to 52 placebo-treated patients matched by baseline National Institutes of Health Stroke Scale (NIHSS) score and nonlacunar anterior circulation location from the Trial of Org 10172 in Acute Stroke Treatment trial using a 1:1 ratio. Univariate and multivariate analyses were performed comparing the rates of symptomatic intracerebral hemorrhage, early neurologic improvement, favorable outcome at 7 days or discharge, and in-hospital mortality between the 2 groups. RESULTS: After adjustment for gender, time interval between symptom onset to treatment, hypertension, hyperlipidemia, and history of cigarette smoking, rates of neurologic improvement at 24 hours (odds ratio [OR] 1.15; 95% confidence interval [CI] 0.43-3.1) and favorable outcome at 7 days or discharge (OR 1.39; 95% CI 0.47-4.05) were similar in the 2 groups. No differences in the rates of symptomatic intracerebral hemorrhage or death were found after adjusting for potential confounders. In an analysis limited to only those patients who underwent computed tomographic perfusion or magnetic resonance imaging before receiving endovascular treatment, the rate of favorable outcome at 7 days or discharge was similar between patients who underwent endovascular treatment and control patients (35.7% v 32.1%; P = .77). CONCLUSIONS: We did not observe any evidence of benefit in halting neurologic worsening or improving outcomes among patients undergoing endovascular treatment for treatment of an anterior circulation ischemic stroke after 6 hours of symptom onset. Strong evidence of both the safety and efficacy of emergent endovascular treatment when administered to patients with stroke in the anterior circulation is needed.

MRI-assisted thrombolysis for delayed arrival among patients with ischemic stroke.

Time window for thrombolysis in acute ischemic stroke can be based on chronological or physiological (imaging) data. Both of these approaches have their unique strengths and weaknesses. The concept of chronological-based thrombolysis is supported by several randomized clinical trials whereas imaging-based thrombolysis has not been validated entirely by randomized trials. Therefore, careful evaluation of strategies using image-based identification of patients who might benefit from thrombolysis is needed. Patients undergoing thrombolysis on delayed arrival appear to be the most logical group in whom image-based strategies should be evaluated.

Agreement in endovascular thrombolysis patient selection based on interpretation of presenting CT and CT-P changes in ischemic stroke patients.

BACKGROUND: To evaluate the agreement in patient selection based on computed tomography (CT) and CT-perfusion (CT-P) imaging interpretation between stroke specialists in stroke patients considered for endovascular treatment. METHODS: All endovascular-treated acute ischemic stroke patients were identified through a prospective database from two comprehensive stroke centers; 25 consecutively treated patients were used for this analysis. Initial CT images and CT-P data were independently interpreted by five board eligible/certified vascular neurologists with additional endovascular training to decide whether or not to select the patient for endovascular treatment. The CT/CT-P images were evaluated separately and used as the sole imaging decision making criteria, 2 weeks apart from each other (memory wash-out period). For each set of imaging data inter-rater and intra-rater agreement scores were obtained using Cohen's kappa statistic to assess the proportion of agreement beyond chance. RESULTS: Kappa values for the treatment decisions based on CT images was 0.43 (range 0.14-0.8) (moderate agreement), and for the decisions based on CTP images was 0.29 (range 0.07-0.67) (fair agreement) among the five subjects. There was substantial variability within the group and between images interpretation. Observed agreement on decision to treat with endovascular therapy was found to be 75% with CT images and 59% with CT-P images (with no adjustment for chance). Kappa values for intra-rater agreement were -0.14 (ranged -0.27-0.27) (poor agreement). CONCLUSIONS: There is considerable lack of agreement, even among stroke specialists, in selecting acute ischemic stroke patients for endovascular treatment based on CT-P changes. This mandates a careful evaluation of CT-P for patient selection before widespread adoption.

Comparison between angioplasty using compliant and noncompliant balloons for treatment of cerebral vasospasm associated with subarachnoid hemorrhage.

BACKGROUND: Considerable controversy exists regarding the choice of balloon used for performing angioplasty as treatment of cerebral vasospasm associated with subarachnoid hemorrhage. OBJECTIVE: To determine the impact of compliant and noncompliant balloons on angiographic and clinical outcomes among patients with subarachnoid hemorrhage-related cerebral vasospasm. METHODS: Consecutive patients with cerebral vasospasm who underwent balloon angioplasty were included. Patient characteristics, rate of angiographic recurrence, and occurrence of cerebral infarcts in the affected vessel distribution were compared between arteries treated using different balloons. RESULTS: A total of 30 patients underwent a first-time angioplasty using compliant (n = 34) or noncompliant (n = 51) balloons. At admission, patients were classified Hunt and Hess grade I to III (n = 20) and Hunt and Hess grade IV to V (n = 10). Fisher grades in patients were I (n = 1), II (n = 3), III (n = 20), and IV (n = 6). No significant differences in the rate of angiographic recurrence (32% vs 53%; P = .14), need for repeat angioplasty (21% vs 20%; P = .97), and occurrence of cerebral infarcts in the affected arterial distribution (21% vs 10% P = .39) were observed with compliant and noncompliant balloons, respectively. Independent of the balloon type, a significant reduction in the need for repeat angioplasty was observed when the initial angioplasty resulted in a normal or supranormal diameter compared with a subnormal diameter (63.5% vs 36.5%; P = .01). CONCLUSION: No clear difference was observed between compliant and noncompliant balloons for therapeutic angioplasty in preventing angiographic recurrence or the need for repeat angioplasty in patients with subarachnoid hemorrhage-related cerebral vasospasm. An immediate normal or supranormal vessel diameter after the first-time angioplasty resulted in a significant reduction in the need for repeat angioplasty.

A multicenter analysis of "time to microcatheter" for endovascular therapy in acute ischemic stroke.

PURPOSE: At present, no time recommendation for initiation of endovascular treatment in acute ischemic stroke is available. A multicenter analysis was designed to identify variables that prolong "time to microcatheter," defined as the time interval from computed tomographic scan to microcatheter placement in the cerebral circulation. METHODS: Consecutive acute ischemic stroke patients from 3 academic stroke centers were included. Analysis of covariance was used to evaluate different variables that prolong "time to microcatheter." RESULTS: Ninety-one patients underwent emergent endovascular treatment for acute ischemic stroke. Mean "time to microcatheter" was 174±60 minutes. No significant time difference was found in patients who were intubated, presented at night or weekends, were administered intravenous recombinant tissue plasminogen activator, or underwent additional imaging prior to endovascular treatment. "Time to microcatheter" was significantly longer in nonlevel I trauma centers and in patients with National Institutes of Health Stroke Scale Score of 10 to 19. CONCLUSION: Wide variability of "time to microcatheter" among institutions highlights the need for standardized time goals.

A comparison of Computed Tomography perfusion-guided and time-guided endovascular treatments for patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: The role of CT perfusion (CT-P) imaging for the selection of patients with acute ischemic stroke who may benefit from endovascular treatment is not defined. The objective of this study was to determine whether CT-P-guided endovascular treatment improves clinical outcomes compared with standard endovascular treatment based on the time interval between symptom onset and presentation and noncontrast cranial CT imaging. METHODS: A retrospective study was performed comparing the clinical characteristics, complications, and clinical outcomes of patients with acute ischemic stroke who were treated using endovascular modalities based on either CT-P imaging (CT-P-guided) or time interval between symptom onset and presentation and absence of intracerebral hemorrhage or extensive ischemic changes on noncontrast cranial CT scan (time-guided). RESULTS: The rates of partial and complete recanalization were similar between the CT-P- and time-guided treatment groups (n=61 [88%] versus n=103 [81%]; P=0.52) regardless of whether they received intravenous recombinant tissue plasminogen activator before endovascular treatment. Comparing the CT-P-guided with the time-guided patients, favorable discharge outcome (modified Rankin Scale 0 to 2) was observed in 23 (32%) versus 41 (33%) of the patients, respectively (P=0.9). In-hospital mortality was observed in 15 (21%) of CT-P- and 29 (23%) of time-guided patients (P=0.74). CONCLUSIONS: CT-P-guided endovascular treatment did not increase the rate of short-term favorable outcomes among patients with acute ischemic stroke. Prospective studies are required to validate the CT-P criteria and protocols currently in use before incorporating CT-P as a routine modality for patient selection for endovascular treatment.

Initial experience in establishing an academic neuroendovascular service: program building, procedural types, and outcomes.

OBJECTIVE: To report our initial experience in setting up a neuroendovascular service in a university-based comprehensive stroke center. METHODS: We determined the rates of referral path, procedural type, and independently adjudicated 1-month outcomes (actual rates) in first 150 procedures (120 patients) and subsequently compared with rates derived from pertinent clinical trials after adjustment for procedural type (predicted rates). RESULTS: The patients were referred from the emergency department (n= 44), transferred from another hospital (n= 13), or admitted for elective procedures from the clinic (n= 63). The procedures included treatment of acute ischemic stroke (n= 12); extracranial carotid stent placement (n= 33); extracranial vertebral artery stent placement (n= 13); intracranial angioplasty and/or stent placement (n= 12); embolization for intracranial aneurysms (n= 35), arteriovenous malformations (n= 5), and tumors (n= 10); cerebral vasospasm treatment (n= 26); and others (n= 4). The technical success rate was 100% for intracranial aneurysm obliteration and extracranial carotid artery stent placement, and 95% for those undergoing intracranial or vertebral artery stent placements; and partial or complete recanalization was achieved in 72% of patients undergoing intra-arterial thrombolysis. After adjusting for procedural type, the actual adverse event rate of 3% compared favorably with the predicted rate of 7% based on the results of clinical trials. CONCLUSIONS: We provide estimates of procedure volumes and outcomes observed in the initial phase of setting up a neuroendovascular service with an active training program.

The value of computed tomography angiography in determining treatment allocation for aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Computed tomography (CT) and CT angiography (CTA) are frequently the initial imaging modalities used in the evaluation of patients with suspected aneurysmal subarachnoid hemorrhage (SAH). It remains unclear whether CTA can provide adequate information to determine best treatment modality (endovascular versus surgical) for ruptured intracranial aneurysms. METHODS: Pertinent clinical and radiological information of consecutive patients with aneurysmal SAH who underwent CTA on a 64-slice multidetector CT (MDCT) scanner were independently reviewed by five endovascular specialists. Subsequently, the interobserver reliability was calculated. RESULTS: A total of 21 consecutive patients with aneurysmal SAH detected on CTA were reviewed. Of the total of 105 reviews, in 65% a treatment allocation decision was made. Responses were, 26% either treatment; 18% endovascular only; 18% surgical only; and 3% neither treatment. In the remaining 35% it was considered that CTA images were inadequate to make a decision for treatment allocation and more information was requested. Interobserver reliability was poor between endovascular specialists (k = 0.2). The reliability was higher among endovascular/vascular neurosurgeons (k = 0.34) and physicians with >5 years of faculty experience (k = 0.55). CONCLUSION: When 64-slice MDCT angiography is used in the evaluation of aneurysmal SAH, the information obtained is adequate to determine treatment modality allocation in two-thirds of the cases. The agreement on best treatment modality varied across primary specialty, practice experience, and site of fellowship completion.

Traumatic Intracranial Aneurysm Formation following Closed Head Injury.

BACKGROUND: Traumatic intracranial aneurysms are rare conditions that can be a result of non-penetrating head trauma. We report the occurrence of intracranial aneurysms in patients with traumatic brain injury. METHODS: All diagnostic cerebral angiograms performed in patients with traumatic brain injury at a level I trauma center from January 2006 to July 2007 were reviewed. RESULTS: Diagnostic cerebral angiography was performed in 74 patients with the diagnosis of closed head injury. A total of 4 traumatic intracranial pseudoaneurysms were found in 4 patients, two in the supraclinoid segment of the internal carotid artery, one in the cavernous segment of the internal carotid artery and one in the paraophthalmic segment of the internal carotid artery. Two patients were treated with coil embolization. One patient had follow up imaging on which there was no change in the size and morphology of the aneurysm. CONCLUSION: Intracranial aneurysms can develop in patients with closed head injury presumably related to shear or rotational injury. It is unclear whether these aneurysms should be classified as traumatic intracranial aneurysms or pseudoaneurysms, but the pathological findings frequently reveal disruption of the three vascular layers fulfilling the definition of pseudoaneurysm. For these reason we favor the name of post-traumatic intracranial pseudoaneurysms.