Thrombectomy and stenting of pseudoaneurysm from transcarotid artery revascularization.

Background: Transcarotid artery revascularization (TCAR) is becoming an increasingly popular treatment of carotid stenosis. Despite this rapid adoption, little in the literature describes the associated complications of this procedure. Case Description: We report a case of a left M1 large-vessel occlusion following treatment of symptomatic, high-grade carotid stenosis with a TCAR procedure approximately three weeks earlier. The initial angiography demonstrated a pseudoaneurysm in the left common carotid artery at the site of TCAR access with a distal clot in the carotid stent. The clot within the stent was aspirated, and a mechanical thrombectomy was performed with a combination of a stent-retriever and aspiration catheter for thrombolysis in cerebral infarction 2B revascularization. Conclusion: The TCAR procedure offers a novel method for revascularization of carotid lesions; it does include its complications. While generally safe, access site complications such as pseudoaneurysms can always occur. Knowledge of this risk allows for appropriate surveillance and management should it occur.

An Endovascular Surgery Experience in Far-Forward Military Healthcare-A Case Series.

INTRODUCTION: The advancement of interventional neuroradiology has drastically altered the treatment of stroke and trauma patients. These advancements in first-world hospitals, however, have rarely reached far forward military hospitals due to limitations in expertise and equipment. In an established role III military hospital though, these life-saving procedures can become an important tool in trauma care. MATERIALS AND METHODS: We report a retrospective series of far-forward endovascular cases performed by 2 deployed dual-trained neurosurgeons at the role III hospital in Kandahar, Afghanistan during 2013 and 2017 as part of Operations Resolute Support and Enduring Freedom. RESULTS: A total of 15 patients were identified with ages ranging from 5 to 42 years old. Cases included 13 diagnostic cerebral angiograms, 2 extremity angiograms and interventions, 1 aortogram and pelvic angiogram, 1 bilateral embolization of internal iliac arteries, 1 lingual artery embolization, 1 administration of intra-arterial thrombolytic, and 2 mechanical thrombectomies for acute ischemic stroke. There were no complications from the procedures. Both embolizations resulted in hemorrhage control, and 1 of 2 stroke interventions resulted in the improvement of the NIH stroke scale. CONCLUSIONS: Interventional neuroradiology can fill an important role in military far forward care as these providers can treat both traumatic and atraumatic cerebral and extracranial vascular injuries. In addition, knowledge and skill with vascular access and general interventional radiology principles can be used to aid in other lifesaving interventions. As interventional equipment becomes more available and portable, this relatively young specialty can alter the treatment for servicemen and women who are injured downrange.

Effect of antiplatelet therapy and platelet function testing on hemorrhagic and thrombotic complications in patients with cerebral aneurysms treated with the pipeline embolization device: a review and meta-analysis.

PURPOSE: The pipeline embolization device (PED) necessitates dual antiplatelet therapy (APT) to decrease thrombotic complications while possibly increasing bleeding risks. The role of APT dose, duration, and response in patients with hemorrhagic and thromboembolic events warrants further analysis. METHODS: A PubMed and Google Scholar search from 2009 to 2014 was performed using the following search terms individually or in combination: pipeline embolization device, aneurysm(s), and flow diversion, excluding other flow diverters. Review of the bibliographies of the retrieved articles yielded 19 single and multicenter studies. A statistical meta-analysis between aspirin (ASA) dose (low dose ≤160 mg, high dose ≥300 mg), loading doses of APT agents, post-PED APT regimens, and platelet function testing (PFT) with hemorrhagic or thrombotic complications was performed. RESULTS: ASA therapy for ≤6 months post-PED was associated with increased hemorrhagic events. High dose ASA ≤6 months post-PED was associated with fewer thrombotic events compared with low dose ASA. Post-PED clopidogrel for ≤6 months demonstrated an increased incidence of symptomatic thrombotic events. Loading doses of ASA plus clopidogrel demonstrated a decreased incidence of permanent symptomatic hemorrhagic events. PFT did not show a statistically significant relationship with symptomatic hemorrhagic or thrombotic complications. CONCLUSIONS: High dose ASA >6 months is associated with fewer permanent thrombotic and hemorrhagic events. Clopidogrel therapy ≤6 months is associated with higher rates of thrombotic events. Loading doses of ASA and clopidogrel were associated with a decreased incidence of hemorrhagic events. PFT did not have any significant association with symptomatic events.

Strategies to minimize complications during intraoperative aneurysmal hemorrhage: a personal experience.

BACKGROUND: The occurrence of intraoperative rupture (IOR) of an aneurysm is one of the most precarious moments in microsurgery, and the management of IOR profoundly affects operative outcomes. METHODS: The authors describe their personal experiences during the past decade with managing intraoperative aneurysm rupture for microsurgical treatment of complex cerebral aneurysm procedures. RESULTS: Steps to avoid and manage IOR depend on the stage of the operation or phase of dissection and on aneurysm location and configuration. The point at which IOR occurs dictates the management options available. The rupture of the aneurysm itself usually does not cause death or disability, but the subsequent actions performed by the surgeon can make the difference between a good and poor outcome. Major complications are caused by the surgeon's premature reaction placing a permanent clip in the face of torrential bleeding without adequate visualization, leading to vascular and cranial nerve injuries. Short videos are provided to illustrate the technical nuances to minimize complications. CONCLUSIONS: Accurate knowledge of the anatomy of the aneurysm and surrounding vasculature is the keystone to prevention and treatment of IOR. Most importantly, the surgeon must not rush prematurely to apply a permanent clip blindly in an effort to stop the hemorrhage.

Advances in surgical approaches to dural fistulas.

Dural arteriovenous fistulas are abnormal connections of dural arteries to dural veins or venous sinuses originating from within the dural leaflets. They are usually located near or within the wall of a dural venous sinus that is frequently obstructed or stenosed. The dural fistula sac is contained within the dural leaflets, and drainage can be via a dural sinus or retrograde through cortical veins (leptomeningeal drainage). Dural arteriovenous fistulas can occur at any dural sinus but are found most frequently at the cavernous or transverse sinus. Leptomeningeal venous drainage can lead to venous hypertension and intracranial hemorrhage. The various treatment options include transarterial and transvenous embolization, stereotactic radiosurgery, and open surgery. Although many of the advances in dural arteriovenous fistula treatment have occurred in the endovascular arena, open microsurgical advances in the past decade have primarily been in the tools available to the surgeon. Improvements in microsurgical and skull base approaches have allowed surgeons to approach and obliterate fistulas with little or no retraction of the brain. Image-guided systems have also allowed better localization and more efficient approaches. A better understanding of the need to simply obliterate the venous drainage at the site of the fistula has eliminated the riskier resections of the past. Finally, the use of intraoperative angiography or indocyanine green videoangiography confirms the complete disconnection of fistula while the patient is still on the operating room table, preventing reoperation for residual fistulas.

An examination of aneurysm rerupture rates with epsilon aminocaproic acid.

BACKGROUND: Epsilon aminocaproic acid (EACA) has been used in the past to prevent cerebral aneurysm rerupture. Recent studies have indicated that short-term treatment with EACA can lower rebleeding rates without significantly increasing ischemic or thrombotic complications or permanent shunt rates. The goal of this study is to determine the efficacy of EACA in the prevention of aneurysm rerupture at a high volume subarachnoid hemorrhage center. METHODS: We conducted a retrospective study of 355 consecutive subarachnoid hemorrhage patients over a 2-year period under our current protocol for EACA use. Patients were divided by presentation time to our institution and whether the patient received EACA. The primary endpoints of the study were rebleeding rates, ischemic complications, thrombotic complications, vasospasm, shunt rates, and outcomes. RESULTS: Rerupture rates were reduced by half in the entire pool of patients on EACA after controlling for Hunt and Hess Scores and Fisher Scores. In patients who received early aneurysm treatment, this effect persisted but was non-statistically significant due to the small numbers of reruptures. In addition, there was no evidence to suggest that EACA increased ischemic or thrombotic complications, vasospasm, or VPS rates. In patients presenting earlier than 24 h to our institution, there was a non-significant trend toward worse outcomes after EACA use. This trend was reversed in patients arriving after 24 h. CONCLUSION: There is evidence to suggest that EACA is protective from aneurysm rerupture without significant ischemic or thrombotic complications when used for less than 72 h. However, if the aneurysm is treated, this effect is modest indicating that early aneurysm treatment remains the gold standard for rerupture prevention.

Patterns of aneurysm recurrence after microsurgical clip obliteration.

BACKGROUND: Microsurgical clip obliteration remains a time-honored and viable option for the treatment of select aneurysms with very low rates of recurrence. OBJECTIVE: We studied previously clipped aneurysms that were found to have recurrences to better understand the patterns and configurations of these rare entities. METHODS: A retrospective review was performed of 2 prospectively maintained databases of aneurysm treatments from 2 institutions spanning 14 years to identify patients with recurrence of previously clipped intracranial aneurysms. RESULTS: Twenty-six aneurysm recurrences were identified. Three types of recurrence were identified: type I, proximal to the clip tines; type II, distal; and type III, lateral. The most common type of recurrence was that arising distal to the clip tines (46.1%), and the least frequently encountered recurrence was that arising proximal to the tines (19.2%). Laterally located recurrences were found in 34.6% of cases. CONCLUSION: We describe 3 different patterns of aneurysm recurrence with respect to clip application: those occurring proximal, distal, or lateral to the clip tines.

Anomalous course of the intracranial internal carotid artery into the orbit: case report.

In this report, a case of anomalous internal carotid artery looping into the orbital apex is presented. The patient was a 41-year-old man with sudden onset headache, suggestive of aneurysmal subarachnoid hemorrhage (SAH). Imaging with CT demonstrated a perimesencephalic distribution of blood. Cerebral angiography confirmed non-aneurysmal, perimesencephalic SAH, but incidentally noted an anomalous left internal carotid artery with a course into the orbital cone. This is the only known example of this anatomic variation. Potential embryological explanations are discussed.

ε-Aminocaproic acid in angiographically negative subarachnoid hemorrhage patients is safe: a retrospective review of 83 consecutive patients.

BACKGROUND: ε-Aminocaproic acid (EACA) has been used to reduce the rate of cerebral aneurysm rerupture before definitive treatment. In centers administering EACA to patients with a subarachnoid hemorrhage (SAH), patients eventually diagnosed with angiographically negative subarachnoid hemorrhage (ANSAH) may also initially receive EACA, perhaps placing them at increased risk for ischemic complications. OBJECTIVE: To evaluate the effect of short-term EACA on outcomes and secondary measures in patients with ANSAH. METHODS: We conducted a retrospective study of 454 consecutive SAH patients over a 2-year period under a current protocol for EACA use. Patients were excluded if a source for the SAH was discovered, yielding a total of 83 ANSAH patients. The patients were assigned to groups that did or did not receive EACA. The primary end points of the study were ischemic complications, pulmonary emboli, vasospasm, ventriculoperitoneal shunting rates, and outcomes. RESULTS: Statistical analysis yielded no significant difference between the 2 arms with respect to any of the end points: vasospasm (P = .65), deep vein thrombosis (P = .51), pulmonary embolism (P = 1.0), stroke (P = 1.0), myocardial infarction (P = 1.0), and ventriculoperitoneal shunt (P = .57). There was no statistically significant outcome difference using the modified Rankin Scale (P = .30). CONCLUSION: Short-term (<72 hour) application of EACA does not result in an increase in adverse events in patients with ANSAH.

Pial arteriovenous fistula resulting from ventriculostomy.

OBJECTIVE: Ventriculostomy complications are well documented in the literature. We report the first known example of an arteriovenous fistula created during passage of a ventriculostomy catheter for the treatment of hydrocephalus. METHODS: A 47-year-old female patient initially presented with a subarachnoid hemorrhage and an anterior communicating artery aneurysm. The patient underwent coil embolization followed by a ventriculostomy catheter for hydrocephalus. After recovery, a follow-up angiogram demonstrated a new arteriovenous fistula at the site of the ventriculostomy. A craniotomy was performed at the site of the ventriculostomy burr-hole site. Indocyanine green videoangiography confirmed the site of the fistula. RESULTS: The fistulous point was coagulated and divided and confirmed with both indocyanine green videoangiography and intraoperative diagnostic angiography. The patient recovered without deficit. CONCLUSION: This is the first reported case of a pial arteriovenous fistula from a ventriculostomy catheter. The formation of a fistula can occur from trauma to cortical arteries and veins at the pial entry site. Although rare, vascular injury and subsequent fistula formation may form in patients in whom catheter tract hemorrhages occur after catheter placement.

Experience with coil embolization of previously clipped aneurysms presenting with rupture.

INTRODUCTION: Endovascular coil embolization has an established role alongside microsurgical clipping in the treatment of aneurysms. We studied previously clipped aneurysms that presented as subarachnoid hemorrhage and were treated by coil embolization. METHODS: A retrospective review was performed of two prospectively maintained databases from two institutions (Cleveland Clinic, Emory University) that spanned 12 years. RESULTS: Seven patients were identified (mean age 56.9 years) who had previously undergone surgical clipping for aneurysm obliteration; six (86%) were previously ruptured. Patients presented with aneurysm rupture with a mean time of 11.5 years (range 4 months to 20 years) following surgical treatment. Aneurysm location included anterior communicating artery (n=4), posterior communicating artery (n=1), internal carotid artery terminus (n=1) and anterior choroidal (n=1). Three patients presented in Hunt and Hess (HH) grade 1, one in HH2, two in HH3 and one in HH4. Four of the patients underwent unassisted coil embolization while balloon assistance was employed in three. Angiographic results were as follows: complete occlusion (n=3; 42.9%) and residual neck (n=4; 57.1%). There were no intraprocedural complications. CONCLUSION: Aneurysm rupture following surgical obliteration is a rare event and may occur remote from the initial treatment. Endovascular embolization with or without balloon assistance can be safely employed in cases of aneurysm recurrence rupture following surgical treatment with satisfactory angiographic treatment.

Microsurgical and endovascular management of pericallosal aneurysms.

BACKGROUND: Pericallosal, or A2 bifurcation, aneurysms are an infrequently encountered cause of subarachnoid hemorrhage (SAH). While the International Subarachnoid Aneurysm Trial showed improved outcomes for patients with any ruptured anterior circulation aneurysm treated with embolization, there was also a higher recurrence rate for embolized aneurysms. Notably, there were relatively few pericallosal aneurysms. OBJECTIVE: Specific analysis of pericallosal aneurysms may help guide therapeutic decisions. METHODS: Retrospective analysis of patients who presented with proven saccular pericallosal aneurysms was performed at two institutions from 1999 to 2009. Patients were stratified according to presentation Hunt and Hess grades and modified Fisher scores, treatment modality and outcomes as well as development of vasospasm, hydrocephalus and required treatment. RESULTS: Eighty-eight patients with pericallosal aneurysms were identified. Sixty-two presented with SAH and 26 in elective fashion, 2 of whom had a prior history of SAH. Fifty-four patients underwent microsurgical repair and 32 endovascular repair. Patients presenting with SAH due to pericallosal aneurysm treated with an endovascular approach were more likely to have a good modified Rankin scale (mRS) (mRS 0-2 vs 3-6) (p=0.028), to make a complete recovery (mRS=0) (p=0.017) and were less likely to die (mRS=6) (p=0.026). Patients with electively treated pericallosal aneurysms did not have statistically significant differences in outcome between surgical and endovascular cohorts. Differences in secondary endpoints did not reach significance. CONCLUSION: Patients with ruptured pericallosal aneurysms fare better with endovascular therapy, with better chance of complete recovery. Surgical and endovascular treatments of unruptured pericallosal aneurysms have similar results and outcome.

Indocyanine green videoangiography for confirmation of bypass graft patency.

OBJECTIVE: The aim of the study is to determine the efficacy of indocyanine green (ICG) videoangiography for confirmation of vascular anastomosis patency in both extracranial-intracranial and intracranial-intracranial bypasses. METHODS: Intraoperative ICG videoangiography was used as a surgical adjunct for 56 bypasses in 47 patients to assay the patency of intracranial vascular anastomosis. These patients underwent a bypass for cerebral ischemia in 31 instances and as an adjunct to intracranial aneurysm surgery in 25. After completion of the bypass, ICG was administered to assess the patency of the graft. The findings on ICG videoangiography were then compared to intraoperative and/or postoperative imaging. RESULTS: ICG provided an excellent visualization of all cerebral arteries and grafts at the time of surgery. Four grafts were determined to be suboptimal and were revised at the time of surgery. Findings on ICG videoangiography correlated with intraoperative and/or postoperative imaging. CONCLUSION: ICG videoangiography is rapid, effective, and reliable in determining the intraoperative patency of bypass grafts. It provides intraoperative information allowing revision to reduce the incidence of technical errors that may lead to early graft thrombosis.

Endovascular treatment of an aneurysm of a persistent primitive hypoglossal artery with complete resolution of brainstem compressive symptoms: case report.

BACKGROUND AND IMPORTANCE: Aneurysms of the posterior circulation may manifest with neurological deficits related to mass effect on the brainstem. We present an unusual case of an aneurysm resulting in selective lower-extremity weakness and gait instability. CLINICAL PRESENTATION: A 61-year-old man presents with progressively worsening gait instability over the course of several months. A magnetic resonance image and computed tomographic angiogram demonstrate a persistent hypoglossal artery associated with an aneurysm invaginating into the pontomedullary junction. The patient manifested only lower-extremity symptoms. An endovascular approach through the right internal carotid artery and persistent primitive hypoglossal artery was assayed, coiling off the aneurysm with complete angiographic occlusion. One month after the procedure, the patient reported marked improvement in symptoms with residual difficulty walking. At the 1-year postprocedure interval, he reported nearly complete resolution of symptoms. CONCLUSION: Endovascular therapy of an aneurysm invaginating into the brainstem is safe and efficacious.

Endovascular therapy of very small aneurysms of the anterior communicating artery: five-fold increased incidence of rupture.

BACKGROUND: Intraprocedural rupture is a dangerous complication of endovascular treatment. Small ruptured anterior communicating artery (ACoA) aneurysms and microaneurysms present a challenge for both surgical and endovascular therapies to achieve obliteration. An understanding of the complication rates of treating ruptured ACoA microaneurysms may help guide therapeutic options. OBJECTIVE: To report the largest cohort of ACoA microaneurysms treated with endovascular therapy over the course of the past 10 years. METHODS: We performed a retrospective review of 347 ACoA aneurysms treated in 347 patients at Cleveland Clinic and Emory University over a 10-year period. Patient demographics, aneurysmal rupture, size, use of balloon remodeling, patient outcomes, intraprocedural rupture, and rerupture were reviewed. RESULTS: Rupture rates were examined by size for all patients and subgroups and dichotomized to evaluate for size ranges associated with increased rupture rates. The highest risk of rupture was noted in aneurysms less than 4 mm. Of 347 aneurysms, 74 (21%) were less than 4 mm. The intraprocedural rupture rate was 5% (18/347) for ACoA aneurysms of any size. There was an intraprocedural rupture rate of 2.9% (8/273) among ACoA aneurysms greater than 4 mm compared with 13.5% (10/74) in less than 4-mm aneurysms. Procedural rupture was a statistically significant predictor of modified Rankin score after adjusting for Hunt and Hess grades (HH). CONCLUSION: ACoA aneurysms less than 4 mm have a 5-fold higher incidence of intraprocedural rerupture during coil embolization. Outcome is negatively affected by intraprocedural rerupture after adjusting for HH grade.

Antithrombotic states and outcomes in patients with angiographically negative subarachnoid hemorrhage.

BACKGROUND: Antithrombotic states are encountered frequently, either because of medical therapy or by preexistent pathological states, and may affect the severity of hemorrhagic strokes such as angiographically negative subarachnoid hemorrhages. OBJECTIVE: To determine the effects of antithrombotic states on the outcomes of patients with angiographically negative subarachnoid hemorrhage by examining data pooled from 2 institutions. METHODS: This is a retrospective review of patients who experienced angiographically negative subarachnoid hemorrhage at 2 institutions over the past 5 years. The patients were grouped into those with and those without an antithrombotic state at time of hemorrhage and were stratified according to presentation, clinical grades, outcomes, need for cerebrospinal fluid diversion, and development of vasospasm. Computed tomography of the head was assessed for bleed pattern and modified Fisher grade. Patients were excluded if a causative lesion was subsequently discovered. RESULTS: There is a statistically significant association between antithrombotic states and poorer presentation, higher Hunt and Hess score, increased amount of subarachnoid hemorrhage, higher modified Fisher grade, increased incidence of vasospasm, hydrocephalus, and poor outcomes as assessed by modified Rankin scale (P < .001). Patients with an antithrombotic state experience worse outcomes even with adjustment for the amount of hemorrhage as assessed by modified Fisher grade (P < .001). CONCLUSION: Patients in an antithrombotic state presenting with angiographically negative subarachnoid hemorrhage present with inferior clinical scores, diffuse hemorrhage patterns, and worse modified Fisher grades and have worse outcomes.