Intraprocedural predictors of post-stent retriever thrombectomy subarachnoid hemorrhage in middle cerebral artery stroke.

BACKGROUND: Stent retriever thrombectomy (SRT) in acute thromboembolic stroke can result in post-thrombectomy subarachnoid hemorrhage (PTSAH). Intraprocedural findings associated with PTSAH are not well defined. OBJECTIVE: To identify angiographic findings and procedural factors during SRT that are associated with PTSAH. MATERIALS AND METHODS: This was a retrospective, observational cohort study of consecutive patients with middle cerebral artery (MCA) acute ischemic stroke treated with SRT. Inclusion criteria were: (1) age ≥18 years; (2) thromboembolic occlusion of the MCA; (3) at least one stent retriever pass beginning in an M2 branch; (4) postprocedural CT or MRI scan within 24 hours; (5) non-enhanced CT Alberta Stroke Program Early CT Score >5. Exclusion criteria included multi-territory stroke before SRT. RESULTS: Eighty-five patients were enrolled; eight patients had PTSAH (group 1) and 77 did not (group 2). Baseline demographic and clinical characteristics were comparable between the two groups. In group 1, a significantly greater proportion of patients had more than two stent retriever passes (62.5% vs 18.2%, P=0.01), a stent retriever positioned ≥2 cm along an M2 branch (100% vs 30.2%, P=0.002), and the presence of severe iatrogenic vasospasm before SRT pass (37.5% vs 5.2%, P=0.02). One patient with PTSAH and associated mass effect deteriorated clinically. CONCLUSIONS: An increased number of stent retriever passes, distal device positioning, and presence of severe vasospasm were associated with PTSAH. Neurological deterioration with PTSAH can occur.

Delayed onset of anterior spinal artery syndrome after repair of aortic coarctation.

STUDY DESIGN: A case report. OBJECTIVE: We report a case of delayed anterior spinal artery syndrome after repair of aortic coarctation in which the symptoms did not appear until 6 months after surgery. SUMMARY OF BACKGROUND DATA: Residual dilatation of the anterior spinal artery after surgery can mimic a dilated intraspinal vein, which could lead to the erroneous diagnosis of spinal arteriovenous malformation as the cause for anterior spinal artery syndrome. METHODS: A 40-year-old man with a history of hypertension underwent surgical bypass of the left subclavian artery to descending thoracic aorta to treat coarctation of the thoracic aorta and had an uncomplicated postoperative course. Six months later, he developed numbness and weakness in his hands. Magnetic resonance image showed abnormal signal within the cervicothoracic spinal cord and prominent flow voids within the ventral spinal canal. Spinal digital subtraction angiography revealed slow flow in a dilated intraspinal vessel. Given the history of aortic coarctation repair, the possibility that this represented a residually dilated anterior spinal artery rather than an arteriovenous malformation was considered and confirmed on magnetic resonance imaging. RESULTS: In our patient, institution of an anticoagulation medication regime resulted in rapid improvement of neurological symptoms, underscoring the importance of the awareness of this phenomenon. CONCLUSION: Delayed anterior spinal artery syndrome after aortic coarctation repair because of anterior spinal artery thrombosis can manifest even 6 months postoperatively. Careful analysis of pre- and postoperative cross-sectional imaging should provide the correct diagnosis. Spinal digital subtraction angiography is probably unnecessary and must be interpreted with caution.

Preoperative embolization of the inferior petrosal sinus in surgery for glomus jugulare tumors.

OBJECTIVE: To compare the outcomes of surgery for glomus tumors involving the jugular foramen with and without preoperative venous embolization of the inferior petrosal sinus (IPS). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Twenty-four patients with paragangliomas involving the jugular foramen treated between 1995 and 2008. INTERVENTION: All patients underwent surgical resection after receiving preoperative angioembolization with or without venous embolization of the IPS. MAIN OUTCOME MEASURES: Total operative duration, estimated blood loss, intensive care unit and total hospital days, and novel postoperative lower cranial nerve deficits were recorded, and appropriate statistical analysis was conducted. RESULTS: Twenty-four patients met inclusion criteria. Fourteen of these patients underwent preoperative embolization of the IPS in addition to angioembolization. The group that did not undergo embolization of the IPS was used as the control group (n = 10). These groups were compared with regard to the above outcome measures. Blood loss and new lower cranial nerve deficits were reduced in the venous embolization group, although neither measure reached statistical significance. Tumor size correlated with increased intraoperative hypotensive events and longer total hospital stay, and these correlations were statistically significant. CONCLUSION: Preoperative embolization of the IPS is possible in many patients undergoing surgery of the jugular foramen. The addition of venous embolization to the traditional arterial embolization of glomus jugulare tumors adds little additional time or expense to the procedure and facilitates control of bleeding once the jugular bulb has been opened.

Extended intracranial applications for ethylene vinyl alcohol copolymer (Onyx): mycotic and dissecting aneurysms. Technical note.

The authors describe the off-label use of Onyx for embolization of fusiform mycotic and dissecting intracranial aneurysms based on their experience with 3 patients treated at the University of Utah Hospital from 2006 through 2007. Technical success in occluding the parent artery/aneurysm was achieved in all patients. There were no complications. The authors conclude that Onyx can be used to achieve occlusion of fusiform mycotic and dissecting intracranial aneurysms in conjunction with parent artery occlusion.

Midterm outcomes of paclitaxel-eluting stents for the treatment of intracranial posterior circulation stenoses.

OBJECT: Symptomatic intracranial vertebral and basilar artery atherosclerotic stenoses carry a high risk of stroke and permanent disability if refractory to maximal medical therapy. The authors conducted a study to determine the technical feasibility and midterm clinical and angiographic outcomes in patients in whom paclitaxel-eluting stents were placed for the treatment of symptomatic intracranial posterior circulation stenoses. METHODS: A retrospective review of medical records and imaging studies was performed for 13 consecutive patients in whom paclitaxel-coated stents were used to treat symptomatic posterior circulation intracranial stenoses between 2002 and 2005. Clinical follow-up data were supplemented by telephone interviews. The technical success rate for stent placement was 100%. One patient (8%) suffered a periprocedural stroke. Twelve patients (92%) underwent clinical follow up for a minimum of 3 months postsurgery, and 11 (92%) of these patients remained asymptomatic after a mean period of 10.9 months. Nine patients (69%) underwent catheter angiographic follow up, and no patient had significant in-stent recurrence of stenosis after a mean period of 5.4 months. CONCLUSIONS: Treatment of intracranial posterior circulation stenoses with drug-eluting stents is technically feasible, and the rate of clinically significant periprocedural complications is low. Rates of stenosis recurrence are reduced compared with those of bare-metal stents in the midterm. Midterm clinical outcome is excellent; no symptom recurrence was observed in this patient cohort.

Intraarterial thrombolysis trials in acute ischemic stroke.

Stroke is a common cause of death and disability in industrialized nations. Technical advances and the increased availability of noninvasive brain imaging techniques have permitted precise and early diagnosis of acute cerebral ischemia. This has made emergent thrombolytic therapy for rapid restoration of cerebral perfusion increasingly possible. Herein, the authors present a review of the clinical trials investigating acute stroke treatment with intraarterial thrombolysis.

Parallel venous channel as the recipient pouch in transverse/sigmoid sinus dural fistulae.

OBJECTIVE: The most common location for dural arteriovenous fistulae (AVFs) is the transverse/sigmoid sinus. We describe our prospective analysis of data for 10 patients with recipient fistulae parallel to the transverse/sigmoid sinus. Recognition of this entity allows embolization of the fistula with preservation of the parent sinus. This report reviews the presentation and angiographic characteristics of the "parallel venous channel" and the treatment results for this series of patients. METHODS: Between 1995 and June 2002, at the medical center of the University of California, San Francisco, we identified 10 patients with a parallel venous channel as the recipient pouch for all arterial input into a transverse/sigmoid sinus AVF. The clinical presentations, angiographic features, endovascular treatments, and outcomes are described. Angiographic follow-up monitoring was performed for 1 to 6 years for all patients with cortical venous drainage (5 of 10 patients). Clinical follow-up periods ranged from 1 to 7 years. RESULTS: All patients presented with pulsatile tinnitus disruptive to sleep. Other symptoms included severe headaches, papilledema and visual disturbances, hemiparesis, and mastoid pain. All 10 parallel venous channels communicated with the transverse or sigmoid sinus. Cortical venous drainage was present in 50% of cases. Endovascular ablative procedures, using either coils or ethanol, were performed for all patients. The parallel venous channel was successfully embolized, with preservation of the transverse/sigmoid sinus, for all 10 patients. There were no major complications. All patients experienced resolution of their symptoms, with no recurrence. CONCLUSION: The existence of a parallel venous channel as the recipient pouch for all arterial inflow in a series of 10 transverse/sigmoid sinus AVFs is described. Endovascular obliteration of the parallel channel, with preservation of the parent sinus, was successfully performed for all 10 patients. Recognition of the parallel venous channel is clinically important for the treatment of transverse/sigmoid AVFs.

Endovascular treatment for dural arteriovenous fistulae of the superior petrosal sinus.

OBJECTIVE: To determine the usefulness of endovascular embolization for treatment of dural arteriovenous fistulae of the superior petrosal sinus. METHODS: We performed a retrospective review of 18 patients treated during a 16-year period. Transarterial and/or transvenous embolizations were performed as a preoperative adjunct or definitive therapy. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores. RESULTS: Fourteen patients (78%) were treated with a combination of endovascular therapy and open surgery, and 4 were treated by embolization alone (22%). Angiographic cure was achieved in all patients (100%). Thirty-day morbidity and mortality were 11 and 0%, respectively. The mean follow-up period was 5.4 years. At the latest follow-up examination, all patients had returned to independent clinical status (Glasgow Outcome Scale scores of 1 or 2). CONCLUSION: Endovascular treatment of dural arteriovenous fistulae of the superior petrosal sinus can result in cure when access to the site of the fistula can be achieved. Preoperative embolization is a safe and effective adjunct to minimize bleeding during open neurosurgery.

Guglielmi detachable coil extraction: suction generated by pusher-wire withdrawal after coil detachment within an intracranial aneurysm.

We present a case of Guglielmi detachable coil extraction into a microcatheter after coil detachment during embolization of a superior hypophyseal artery aneurysm; extraction was a result of the suction generated during pusher-wire withdrawal. Experimental simulations using many coil and microcatheter combinations were used to identify factors that contribute to the likelihood of this phenomenon.

Endovascular strategies for carotid cavernous and intracerebral dural arteriovenous fistulas.

Interventional neuroradiology is a less invasive modality than open neurosurgery for the treatment of a wide range of neurovascular disorders. Refinements in technique and improvements in the design of microcatheters, guide wires, and embolic materials have yielded superior clinical outcomes and provided an impetus to treat more of these lesions endovascularly rather than surgically. Endovascular therapy is the standard of care for direct and indirect carotid artery cavernous sinus fistulas and may also be curative for dural arteriovenous fistulas (AVFs) in other locations. The authors provide review of the clinical features, pathophysiology, and management of intracranial AVFs focusing on contemporary endovascular treatment options.

Vascular myelopathies-vascular malformations of the spinal cord: presentation and endovascular surgical management.

Spinal cord vascular malformations are often a cause of spinal myelopathy. Endovascular surgical approaches to spinal cord vascular malformations have become an important adjunct and often the primary treatment of these disorders. Spinal cord vascular malformations may be divided into several categories based on their anatomy and location. They may present with a wide range of symptoms far removed from the vascular pathology. Early recognition and treatment can effect a better outcome and often reverse presenting neurologic deficits. Emerging magnetic resonance imaging techniques allow visualization of flow voids, some vascular anatomy, and intramedullary pathology and are a good screening modality. However, selective diagnostic spinal angiography remains the study of choice to diagnose and elaborate on the anatomy and potential treatment protocols. Rapidly evolving endovascular techniques and technology are revolutionizing the treatment of vascular pathology in the central nervous system, either as an adjunct to traditional neurosurgical techniques or as definitive therapy. We review the diagnosis and treatment options for spinal cord vascular malformations.

Percutaneous vertebroplasty: an emerging therapy for vertebral compression fractures.

Osteoporosis is a debilitating disease that occurs in epidemic proportions in Western societies and has a large economic impact. Percutaneous vertebroplasty is successful in alleviating subacute and chronic pain caused by osteoporotic compression fractures and pathological vertebral fractures from tumor infiltration. The technique is safe and can be performed on an outpatient basis utilizing high-resolution fluoroscopy.