Carotid Stenting as Definitive Treatment for Free Floating Thrombus-Review of 7 Cases.

BACKGROUND AND PURPOSE: Free floating thrombus (FFT) is a rare condition. The optimal treatment strategy is yet to be determined although medical management with anticoagulation is the mainstay. This article reports experience of treating FFT with carotid stenting. METHODS: A retrospective analysis of a prospectively maintained database was performed to identify all patients with FFT treated with carotid stenting. For each patient the demographic data, clinical presentation, location of the thrombus, type of stent and use of adjunctive devices, e.g. balloon guide catheters, clinical and radiological follow-up information as well as complications were recorded. RESULTS: A total of 7 patients, 4 female, with mean age of 55.6 ± 14.5 years were identified. The median National Institutes of Health Stroke Scale (NIHSS) was 7 (range 0-13) at presentation. Free floating thrombus was seen on the left in the majority of cases (n = 6, 85.7%). None of the patients had intracranial large vessel occlusion. The FFT was located in the CCA in 2 cases (28.6%) and the proximal ICA in the remaining 5 cases (71.4%). The Wallstent was used in 5 patients and a cGuard stent used in 2 patients. In 1 patient 2 overlapping stents were used but a single stent was used in the remaining patients. In 6 cases a distal filter wire was used and in 2 cases a balloon guide catheter was used as embolic protection. There were no intraoperative complications and no cases of distal clot migration or intracranial large vessel occlusion during the procedure. At last follow-up (n = 7) 6 patients were recorded as modified Rankin Scale (mRS) ≤2 and 1 patient was mRS 3. CONCLUSION: Free floating thrombus of the carotid arteries can be managed with stenting.

Anomalous origin of the middle meningeal artery from the inferolateral trunk with an arterial circle around a hypoplastic internal carotid artery in an infant with a dural arteriovenous fistula.

Deviations from normal embryologic development can manifest in different anatomical variants of the ophthalmic artery. We present a case of an infant treated for a high-flow dural arteriovenous fistula of the superior sagittal sinus, in whom an arterial circle involving the ophthalmic artery, the middle meningeal artery, the inferolateral trunk and a hypoplastic segment of the internal carotid artery was found. The embryologic development is briefly reviewed with emphasis on the possible genesis of this interesting constellation.

Mechanical thrombectomy for recurrent large vessel occlusion.

Although mechanical thrombectomy (MT) has been shown in numerous trials to be a successful treatment option for patients with large vessel occlusion (LVO), there is limited information on the safety and effectiveness of the technique in cases of recurrent LVO. To this end, we performed a retrospective review of our prospectively maintained database to identify all patients that had undergone more than one MT procedure January 2008 and January 2018. The data collected on these patients included baseline demographics and any history of diabetes mellitus, hypercholesterolaemia, hypertension, atrial fibrillation or smoking. We also recorded when the symptoms had started, the patient's NIHSS and ASPECT scores, the number of passes taken, the patient's final TICI score, any complications which arose and the patient's mRS at 90 days. Our dataset encompassed 25 patients (of which 17 (68%) were female) who had undergone a total number of 52 MT's. Average age at 1st presentation was 70 ±â€¯12.8 years. The median time between one stroke and the next was 71 days (range 1-1059, IQR 183 days). The majority of the strokes were deemed cardioembolic (86.5%) in origin. There was no significant difference in the procedure times, number of passes or TICI scores. There was a significant difference in the mRS after the 1st and 2nd events (p = 0.014) but no significant difference if the 2nd event occurred contralateral to the 1st event (p = 0.66) (n = 22). It is therefore concluded that recurrent thrombectomy can be safely performed with no significant difference in the technical aspects of the procedure.

Basilar artery perforator aneurysms: Report of 9 cases and review of the literature.

Basilar perforator artery aneurysms (BAPA's) are an under-recognised cause of sub-arachnoid haemorrhage (SAH). We present our single centre experience of BAPA's and review of the literature. We performed a retrospective review of our prospectively maintained database to identify all BAPA's that presented acute SAH between February 2009 and February 2018. We identified 9 patients (male = 7), each with a single aneurysm, and average age 55 ±â€¯9.7 years. All aneurysms were small, 2.1 ±â€¯0.5 mm (range 1-3 mm). Three aneurysms were not detected on initial angiography. Six aneurysms were treated with flow diversion, 3 were managed conservatively. No repeat haemorrhage occurred in the flow diverted patients. One patient treated conservatively suffered a repeat haemorrhage and died (mRS 6). Follow up imaging (n = 7), at average 5.6 months (range 3-12 months), showed complete occlusion in all the flow-diverted aneurysms and no change in one conservatively managed patient. There was no evidence of perforator infarction on the follow-up post treatment imaging. Clinical follow-up data was available in 8 patients, 6 of whom (75%) had a good outcome (mRS ≤ 2). A high index of suspicion is required to diagnose BAPA. Flow diversion can be used to treat BAPA's with acceptable risk of perforator infarction and low risk of repeat haemorrhage.

Endovascular Treatment of Dural Arteriovenous Fistulas of the Anterior or Posterior Condylar Vein : A Cadaveric and Clinical Study and Literature Review.

Dural arteriovenous fistulas (DAVF) involving the anterior and posterior condylar vein at the skull base are rare but important to recognize. Due to the highly variable anatomy of the venous system of the skull base, detailed anatomical knowledge is essential for correct diagnosis and appropriate treatment of these lesions. In this report we review the normal anatomy of the condylar veins and describe rare and, to our knowledge, not previously reported anatomical variants. We also highlight the treatment modalities for these lesions with focus on the endovascular transvenous occlusion based on four consecutive cases from our center.

High-Grade Dural Arteriovenous Fistulas : Use of Kaneka ED Coils with the Marathon Microcatheter for Transvenous Coil Embolization.

BACKGROUND: Dural arteriovenous fistulas (DAVF) are commonly encountered lesions that can be treated both transvenously, transarterially or using a combined approach. OBJECTIVE: Transvenous coil embolization of DAVF is a recognized treatment option but can be challenging. In this context this article presents clinical experience using the Kaneka ED10 ExtraSoft coils in combination with the Marathon microcatheter to treat high grade DAVF. The physical properties of these coils and the microcatheter were also determined. MATERIAL AND METHODS: All patients with high grade DAVF treated with the Marathon and the Kaneka ED COIL ∞10 ExtraSoft coils were retrospectively identified. The clinical presentation, location, grade of the lesion, clinical and radiological follow-up data were recorded. Bench side studies were performed to determine the physical properties of the Marathon catheter in comparison to the SL10 and Headway Duo as well the maximum width of the Kaneka pusher wire in comparison to Hypersoft, Target and Axium Prime coils. RESULTS: A total of 8 patients with 9 DAVF with 3 Cognard 3 and 6 Cognard 4 lesions were identified. All the DAVF's were occluded either at the end of the procedure or on follow-up imaging. On bench side tests the Marathon microcatheter had the most flexible distal tip and distal shaft in comparison to the SL10 and Headway Duo. The proximal shaft of the Marathon was stiffer than the SL10. The Kaneka ED COIL ∞10 ExtraSoft had the smallest distal width and were the only coils tested that could be deployed through a Marathon microcatheter. CONCLUSION: The combination of the Marathon microcatheter and Kaneka ED COIL ∞10 ExtraSoft is useful for the treatment of high grade DAVF.

Microsurgical clipping and endovascular flow diversion of ruptured anterior circulation blood blister-like aneurysms.

BACKGROUND: Detection and treatment of blister-like intracranial aneurysms as a source of subarachnoid hemorrhage (SAH) can be challenging. In the past the results of both microsurgical and endovascular treatment were difficult. We present our experience with the treatment of blister-like aneurysms in the acute phase of SAH using microsurgical clipping, endovascular parent vessel occlusion or flow diversion. METHODS: A retrospective analysis of the cases of eight consecutive patients presenting in the acute phase after SAH from an intracranial blister aneurysm was performed. The demographic data of the patients, aneurysm characteristics, the clinical results of the treatment and the follow-up examinations were recorded. Procedural safety margins and aneurysm occlusion on follow-up digital subtraction angiography were the main interest of this evaluation. RESULTS: Between January 2012 and November 2017 a total of eight ruptured blister aneurysms were treated in our center, six patients endovascularly. Five patients were treated in the acute phase of SAH, four by flow diversion. All endovascular procedures were feasible and no procedure-related complications were observed, especially no recurrent hemorrhage. In the first angiographic follow-up all blood blister-like aneurysms were completely occluded; two of the six patients treated by flow diverter implantation showed mild, transient intimal hyperplasia without clinical symptoms or the need for treatment. CONCLUSIONS: Endovascular flow diversion is a viable option in the acute phase after SAH due to the rupture of a blister aneurysm. Implants with reduced thrombogenicity, obviating dual-platelet function inhibition, and flow diverters for vessel bifurcations would extend the indications for this treatment modality.

Endovascular Thrombectomy in Wake-Up Stroke and Stroke with Unknown Symptom Onset.

BACKGROUND AND PURPOSE: Mechanical thrombectomy in acute ischemic stroke within 6 hours of symptom onset is effective and safe. However, in many patients, information on the beginning of symptoms is not available. Patients can be divided into those with wake-up stroke and daytime-unwitnessed stroke. Evidence on outcome and complications after mechanical thrombectomy in wake-up stroke and daytime-unwitnessed stroke is rare. A potential beneficial effect of mechanical thrombectomy in selected patients with wake-up stroke or daytime-unwitnessed stroke is suspected. MATERIALS AND METHODS: We analyzed 1073 patients with anterior circulation stroke undergoing mechanical thrombectomy between 2010 and 2016. Patients with wake-up stroke and daytime-unwitnessed stroke were compared with controls receiving mechanical thrombectomy as the standard of care. We assessed good functional outcome (mRS ≤ 2 at 3 months), mortality rates, and frequencies of symptomatic intracranial hemorrhage. Subgroup analyses tried to detect influences of patient selection via further imaging modalities (MR imaging, CTP; wake-up stroke [advanced], daytime-unwitnessed stroke [advanced]) on outcome and safety. RESULTS: There was no significant difference in good functional outcome between patients with wake-up stroke and controls (35.9% versus 38.3%, P = .625). Outcome in patients with daytime-unwitnessed stroke was inferior compared with controls (27.3%, P = .007). Groups did not differ in all-cause mortality at day 90 (P = .224) and the rate of symptomatic intracranial hemorrhage (P = .292). Advanced imaging improved the frequency of good functional outcome (non-wake-up stroke [advanced] versus wake-up stroke [advanced]: OR, 2.92; 95% CI, 1.32-6.45; non-daytime-unwitnessed stroke [advanced] versus daytime-unwitnessed stroke [advanced]: OR, 2.09; 95% CI, 1.03-4.25) with an additional reduction in all-cause mortality (non-daytime-unwitnessed stroke [advanced] versus daytime-unwitnessed stroke [advanced]: OR, 0.42; 95% CI, 0.20-0.88). CONCLUSIONS: Mechanical thrombectomy in selected patients with wake-up stroke allows a good functional outcome comparable with that of controls. Outcome after mechanical thrombectomy in daytime-unwitnessed stroke seems to be inferior compared with that in controls. Advanced imaging modalities may increase the frequency of good functional outcome in both patients with wake-up stroke and daytime-unwitnessed stroke.

Difference in aneurysm characteristics between ruptured and unruptured aneurysms in patients with multiple intracranial aneurysms.

BACKGROUND: The risk of aneurysmal rupture is dependent upon numerous factors, however, there are inconsistencies in the results between studies, which may be due to confounding factors. This can be avoided by comparing the characteristics of ruptured and unruptured aneurysms within the same patient. We sought to analyze the aneurysm characteristics of patients with acute aneurysmal subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms. METHODS: We reviewed our prospectively maintained institutional database, between 01/10/2007 and 01/01/2017, for all patients with confirmed SAH and >1 aneurysm. We recorded the size, location, and morphology and calculated secondary geometric indices such as bottleneck factor and aspect ratio. RESULTS: During the study period, a total of 694 patients with aneurysmal SAH were admitted to our institution. We identified 113 patients (74.3% female, average age 51.7 ± 12.3). The majority of patients had only one associate unruptured aneurysm (79.6%). The average unruptured aneurysm was 3.1 ± 1.5 mm and the average ruptured aneurysm was 5.7 ± 2.7 mm (P < 0.001). In the multivariate analysis, aneurysm location, aneurysm morphology, and size were independently associated with rupture. A complex aneurysm morphology was the strongest risk factor for rupture (OR, 29.27; 95% CI 14.33-59.78; P < 0.001) with size >7 mm (OR, 17.74; 95% CI 4.07-77.35; P < 0.001), and AcomA location also showing a strong independent association. CONCLUSION: Size plays an important part in determining rupture risk, however, other factors such as location and in particular morphology must also be considered. We believe that the introduction of vessel wall imaging will help to risk stratify aneurysms.