Case examples in the this blog

5:47 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 Spine
  1. An Unusual case of hematomyelia
Aneurysm
  1. Intracranial HIV vasculopathy with multiple aneurysms
  2. Embolisation of Dissecting basilar artery aneurysm
  3. Stent induced spasm during coiling of a vertebral artery dissecting aneurysm
  4. Post traumatic ophthalmic artery pseudoaneurysm
  5. Spontaneous occlusion of posterior cerebral artery aneurysm
  6. Fenestrated posterior inferior cerebellar artery with concomitant vertebro-basilar junction fenestration and vertebral artery aneurysm
  7. Basilar artery dissecting aneurysm treated by flow diversion with Enterprise stent only
  8. Flow diversion treatment of internal carotid artery blister aneurysm with Enterprise stent
  9. Internal carotid artery perforation by microguidewire during Acom artery aneurysm coiling
AVM


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Higher Incidence of In-Hospital Complications in Patients With Clipped Versus Coiled Ruptured Intracranial Aneurysms

4:42 PM Posted by Dr Subhash Kumar, MBBS, MD, DM


An excellent paper from Toronto. the authors have examined the  Registry of the Canadian Stroke Network to evaluate 931 patients and found significantly increased complication rates, mortality, increased hospital stay in patients undergoing clipping as opposed to coiling.

Link to the article in the journal website

Higher Incidence of In-Hospital Complications in Patients With Clipped Versus Coiled Ruptured Intracranial Aneurysms

  1. Mervyn D.I. Vergouwen, MD, PhD; 
  2. Jiming Fang, PhD;
  3. Leanne K. Casaubon, MD, MSc, FRCPC; 
  4. Melissa Stamplecoski;
  5. Annette Robertson, RN, RDCS; 
  6. Moira K. Kapral, MD, MSc, FRCPC;
  7. Frank L. Silver, MD, FRCPC on behalf of the Investigators of the Registry of the Canadian Stroke Network
From the Department of Medicine, Division of Neurology (M.D.I.V., L.K.C., F.L.S.) and Division of General Internal Medicine and Clinical Epidemiology and Women's Health Program (M.K.K.), University Health Network, University of Toronto, Toronto, Canada; Utrecht Stroke Center, Department of Neurology and Neurosurgery (M.D.I.V.), University Medical Center Utrecht, Utrecht, the Netherlands; the Department of Health Policy, Management and Evaluation (M.K.K.), University of Toronto, Toronto, Canada; the Institute for Clinical Evaluative Sciences (J.F., M.S., A.R., M.K.K., F.L.S.), Toronto, Canada; and the Canadian Stroke Network (M.K.K., F.L.S.).
  1. Correspondence to Mervyn D.I. Vergouwen, MD, PhD, Utrecht Stroke Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands. E-mailm.d.i.vergouwen@umcutrecht.nl

Abstract

Background and Purpose—After aneurysmal subarachnoid hemorrhage (SAH), patients with clipped aneurysms have a higher incidence of neurocognitive deficits and seizures compared with patients with coiled aneurysms. It remains unknown if patients with clipped aneurysms also have a higher incidence of other in-hospital complications.
Methods—We used data from the Registry of the Canadian Stroke Network on consecutive patients admitted to hospital with aneurysmal SAH. Patients who died within 2 days after admission were excluded. Baseline characteristics, incidence of various in-hospital complications within 30 days after admission, length of stay, poor functional outcome (modified Rankin Scale score at discharge of ≥3), and mortality were compared between patients with clipped versus coiled aneurysms.
Results—Of the 931 patients, 548 (59%) were clipped and 383 (41%) coiled. Baseline characteristics were similar. Compared with patients with coiled aneurysms, patients with clipped aneurysms had a higher incidence of in-hospital complications (37.2% versus 24.5% of patients; P<0.0001), poor functional outcome at discharge (69.4% versus 51.4%; P<0.0001), mortality (at discharge: 14.6% versus 9.1%; P=0.01), and a longer length of stay (17 [interquartile range, 11 to 29] versus 13 [interquartile range, 7 to 22] days; P<0.0001). Higher incidences were observed for urinary tract infection (P=0.02), pneumonia (P=0.01), cardiac/respiratory arrest (P=0.007), seizure (P=0.01), and decubitus ulcer (P=0.02). Urinary tract infection, pneumonia, cardiac/respiratory arrest, and seizure were independent predictors of poor functional outcome.
Conclusions—Patients with clipped aneurysms have a higher incidence of in-hospital complications than patients with coiled aneurysms, which attributes to a higher risk of poor functional outcome and death and an increased length of stay.


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Basilar artery recanalization status after endovascular therapy does not predict outcome

1:23 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Acute basilar artery occlusion is a devastating phenomenon and not clearly understood. The authors of this present study try to state the same. They did not find any better clinical results even after endovascular interventions. However, I feel there clearly is a benefit of the same at least in a subset of patients. The authors probably need to look at their interventional skills, clinical management, decision making skills and the ability to choose the right patient.

J NeuroIntervent Surg

2010;2:A48-A49 doi:10.1136/jnis.2010.003251.58

Basilar artery recanalization status after endovascular therapy does not predict outcome

  1. K Raghuram, A Rai

Radiology, West Virginia University, West Virginia, USA

Abstract

Purpose Basilar artery occlusion is a devastating event without treatment. With the advent of mechanical and endovascular therapy, one would expect an improvement in outcomes.

Materials and methods We retrospectively reviewed patient records on 17 patients who presented with acute basilar artery thromboembolism and underwent an interventional procedure. The admission clinical findings, CT and CT angiogram, angiographic images and follow-up CT/MRI were reviewed. Clinical follow-up was also recorded. Statistical methods to analyze the findings were performed using JMP software.

Results 12% of patients had a good outcome and 18% were lost to follow-up. NIH stroke scale at admission had a direct correlation with outcome (modified Rankin scale). Recanalization did not directly correlate with outcome. Postprocedure hemorrhage was higher with larger doses of tissue plasminogen activator (tPA) and adding a mechanical device (MERCI) did not significantly improve outcome compared with tPA. Older age, higher admission National Institutes of Health Stroke Scale (NIHSS) were indicators of an adverse outcome. Complete basilar occlusion was associated with a worse outcome than a partial occlusion but the difference did not approach statistical significance.

Conclusions In this single center experience analysis, we were unable to identify any statistically significant angiographic predictors of outcome. Specifically, recanalization of the basilar artery did not correlate with good outcome. NIHSS at admission was an independent predictor of outcome. Basilar occlusion remains a complex and debilitating condition that is not satisfactorily treated by any current methods, including interventional techniques


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Predicting aneurysm rupture- Energy Loss, a new hemodynamic parameter

1:20 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Which aneurysm ruptures and which don’t---the Holy Grail of  aneurysm research…gets a new weapon in the armoury…with a new objective parameter: the Energy loss. Basically it is just another way of looking at the flow dynamic data derived from so many new softwares available. nevertheless, important to have a look….

J NeuroIntervent Surg

2010;2:A8 doi:10.1136/jnis.2010.003244.18

A new hemodynamic parameter: energy loss to anticipate aneurysm rupture
  1. H Takao1, Y Murayama1, Y Qian1,A Mohamed2, W Matsuda3, M Umezu3, T Abe1
  2. 1Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
  3. 2Research and Collaboration Group, Siemens-Asahi Medical Technologies Ltd, Tokyo, Japan
  4. 3Center for Advanced Biomedical Sciences, Waseda University, Tokyo, Japan

Abstract

Purpose Different hemodynamic models have been studied for the need to estimate the rupture risk of cerebral aneurysms with variable success. We postulated that the transfer of energy by the interaction of the hemodynamic forces with the aneurysmal wall can be related to the risk of rupture. For that reason we introduced a new hemodynamic parameter called energy loss (EL).

Methods 40 side wall, medium sized aneurysms were selected from our aneurysm database from 2003 to 2009. Four incidentally found internal carotid posterior communicating artery aneurysms ruptured during their period of conservative observation (ruptured-IA). 36 stable unruptured aneurysms (stable-IA) with the same location and similar size were examined with EL.

EL is created by separation and turbulence of the flow. We subtracted without aneurysm energy from with aneurysm energy in our model. To avoid the influence from size of aneurysms, the EL was divided by the aneurismal volume.

Results The flow inside the ruptured IAs appeared more complex, and it crashed strongly into aneurysm surfaces. In contrast, the flow inside of stable-IAs passed smoothly through the aneurysms.

The EL in ruptured-IAs was about five times higher than that of stable-IAs.

Conclusion The research indicated that there is a more complex flow pattern with significant turbulence inside of ruptured-IA. The EL created by aneurysms was clearly different between ruptured-IA and stable-IA. The results indicate that the EL may be an important parameter to estimate the risk of aneurysm rupture and that potentially can be developed into clinical application.

F1[4]

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New Device: The Temporary Aneurysm Neck Bridge System

1:18 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

J NeuroIntervent Surg 2010;2:A8-A9 doi:10.1136/jnis.2010.003244.19
SNIS 7th Annual Meeting  Oral abstract

Novel non-occlusive temporary endoluminal neck protection device to assist in the treatment of wide necked aneurysms in a canine model

  1. R Turner IV1,
  2. B Croy1,
  3. D Casigny2,
  4. I Chaudry3,
  5. A Turk3
1Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
2Neuroradiology, University of Wisconsin, Madison, Wisconsin, USA
3Neuroradiology, Medical University of South Carolina, Charleston, South Carolina, USA

Abstract

Introduction Current endovascular treatment of wide necked aneurysms often requires the use of an adjuvant device. Balloon assist technique requires temporary occlusion of the parent vessel. Intravascular stents require the use of antiplatelet medication. A novel device which achieves temporary neck protection without parent vessel occlusion or antiplatelet medication is examined in a canine model.
Method 20 sidewall, wide necked aneurysms were created in 10 canines, one in each carotid artery, using a vein graft technique and allowed to mature. In each canine, one aneurysm was catheterized with a microcatheter while the temporary aneurysm neck bridge system (TANBS) was unsheathed across the neck of the aneurysm and the aneurysm was coiled. The second aneurysm in each canine was coiled without an adjunctive device. The TANBS was assessed for coil herniation, coil entrapment within the device, trackability, deliverability, TANBS deployability, TANBS recapturabilty and radio-opacity. The five animals were sacrificed acutely and five were sacrificed at 28 days and the carotid artery was explanted and sent for necropsy to assess for injury to the endothelium.
Results There were 17 aneurysms present for coiling out of the 20 aneurysms originally created. Three aneurysms thrombosed were occluded on angiography at the time of coiling. Ten of the aneurysms, one in each of the canines, were coiled to occlusion while the TANBS device was deployed across the neck of the aneurysm. The seven remaining aneurysms located on the contralateral carotid artery were coiled to occlusion without assistance.
The TANBS was successfully moved through the delivery, navigated into position across the aneurysm neck, deployed, resheathed and removed without adverse events in all cases. The coils were successfully placed into the aneurysms without evidence of coil herniation around the device or through its interstices. During device resheathing there was no evidence of interaction with the deployed coils as evidenced by movement of a coil loop or change in configuration of the coil mass. There was no change in the aneurysm occlusion result following the removal of the device. The radio-opacity of the device was adequate using GE/OEC 9800 C-Arm. Angiography did not reveal evidence of vasospasm or vessel dissection following removal of the device.
Two coiled aneurysm in each group had mild fibroblasts on histology. The largest aneurysm was associated with the greatest degree of fibrosis. Three specimens in two canines were associated with severe inflammation, with both aneurysms in one canine, and the control aneurysm in a second animal. A third animal had a moderate–severe inflammatory response in the TANBS group. All other aneurysms were associated with minimal or mild inflammatory response. Overall, fibrosis was greatest in the chronic (28 day) group, while inflammation was most prominent in the acute group. There were no cases of parent vessel endothelial injury, perforation or intramural dissection.
Conclusion The TANBS device was technically successful in all cases and provided parent artery protection as it was intended with no adverse events related to its use. Necropsy demonstrated that there was no evidence of endothelial injury related to the device.


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Balloon assisted coiling of intracranial aneurysms is not associated with higher complications

1:18 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Smile Finally, an to my delight. Balloon assisted coiling has many benefits including prevention of rupture, immediate bleeding control after intraprocedural rupture, better coil packing coil prolapse, and avoidance of stent with the resultant antiplatelet therapy. However, its usage was considered ‘risky’ especially by people not really skilled in the art of neurointervention, even though its the favoured technique of the senior pro.
J NeuroIntervent Surg
2010;2:A12 doi:10.1136/jnis.2010.003244.26
  • Balloon assisted coiling of intracranial aneurysms: complication comparison between non-assisted and balloon assisted procedures
  1. J Perl II, J Fease, D Tubman, B Crandall
  2. Interventional Neuroradiology, Minneapolis Neuroscience Institute, Minneapolis, Minnesota, USA

Abstract

Background and purpose There is still a question in the current literature as to whether the addition of balloon assistance in intracranial aneurysm embolization procedures increases thromboembolic and intraoperative perforation complications. The purpose of this study was to determine if balloon assisted coiling (BAC), given the use of an additional device, increases complications compared with conventional coiling of intracranial aneurysms.
Methods Between June 2002 and February 2010, 845 consecutive intracranial aneurysm embolization procedures were assessed. Of these procedures, 640 (207 ruptured) procedures had a high compliant balloon (Hyperform (73.8%) or Hyperglide (25.8%); eV3 Corp) inserted during the procedure; 205 (127 ruptured) procedures had no adjunctive devices inserted during the course of the procedure. Procedures utilizing stent assistance were excluded from the study. Procedures were performed by three different interventionalists at a single center. Procedural thromboembolic complications, intraoperative perforations, hospital course complications and Glasgow Outcome Score were reviewed and recorded retrospectively and prospectively. Comparisons between the techniques were also made between ruptured and unruptured aneurysms. Results were analyzed using the Student t test; p values <0.05 were considered statistically significant.
Results With BAC, 88.8% of procedures had no complications whatsoever (85.0% ruptured, 90.5% unruptured) and with conventional coiling, 84.9% (80.1% ruptured, 92.3% unruptured) (p=0.168) of procedures had no complications. Thromboembolic complications with clinical sequelae occurred more during conventional coiling (7.3%; 15/205) than BAC (1.1%; 7/640) (p=0.001). Intraoperative perforation occurrences were not statistically significantly different (2.8% BAC versus 1.5% conventional coiling; p=0.20)). Of the intraoperative perforations with BAC, only 38.9% (7/18) occurred while the balloon was inflated. In 33.3% (6/18), the balloon was inflated only after perforation by coil or microcatheter. In 11.1% (2/18), the balloon was only inserted after the perforation had occurred, 5.6% (1/18) occurred during angioplasty and in 11.1% (2/18) extravasation was seen immediately after procedure termination. In the BAC procedures, 94.8% had no hospital course complications (90.8% ruptured, 96.8% unruptured) and in conventional coiling procedures, 85.9% (78.0% ruptured, 98.7% unruptured) had no hospital course complications. Glasgow Outcome Score in ruptured and unruptured aneurysms showed no statistically significant difference in BAC procedures compared with conventional coiling procedures.
Conclusion The use of balloon assistance in intracranial aneurysm embolization procedures does not increase technical or clinical complications compared with embolization procedures without balloon assistance.


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New Device: The Saddle Neck Bridge Device

1:17 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

The treatment of wide necked bifurcation aneurysms had always been difficult notwithstanding the recent usage of Y-stent technique, Double catheter technique, Waffle cone technique, double balloon technique etc . etc. etc. The author in this paper have tried a new device which look promising in that at least it is providing a better looking scaffold and support to so to allow a more anatomically correct coiling.
J NeuroIntervent Surg 2010;2:A9 doi:10.1136/jnis.2010.003244.20
  • Preliminary experience with a novel neck bridge device for bifurcation aneurysm treatment
  2. 1Division of Interventional Neuroradiology, UCLA Medical Center, Los Angeles, California, USA
  3. 2Medical University of South Carolina, Charleston, South Carolina, USA

Abstract

Background Endovascular stenting for wide necked aneurysms has become common practice since the release of the Neuroform and more recently the Enterprise stent systems. However, intrinsic to their design, these devices are indicated for the treatment of side wall aneurysm morphologies. We present a novel neck bridge device that recently received HUD approval that simulates a stent for the treatment of bifurcation aneurysms.
Methods This novel neck bridge device composed of several nitinol wires formed to create a virtual saddle shape that covers the ostium of a bifurcation or terminal configuration aneurysm. The device is designed to deliver through a 0.021″ microcatheter and is resheathable/recaptureable up until detachment so it can be used temporarily or detached and left permanently. Multiple human basilar wide necked aneurysms were mechanically simulated in a silicone benchtop model. The device was deployed across the aneurysm ostium and detached. Then an SL-10 microcatheter was advanced across the neck bridge device and into the aneurysm, and aneurysm coiling performed using standard techniques. Next, these same steps were repeated in two experimentally created bifurcation aneurysms in canines. These animals were then survived for 60 days and explanted. Further animal work is currently underway and those results will be presented if available.
Results The saddle neck bridge device was able to be successfully and easily deployed across the aneurysm neck in all instances. All aneurysms were able to be catheterized and coiled without difficulty. In no instance was there prolapse of coil loops through or around the device. Histologic evaluation demonstrated neoendothelial growth over the device struts without evidence of overt or abnormal inflammation or vessel trauma.
Conclusion The saddle neck bridge device is a novel endovascular stent like device that is designed to treat bifurcation aneurysms. Preliminary benchtop and animal modeling demonstrate the device to be safe and feasible for bifurcation aneurysm treatment. It is likely that this device in combination with coils will allow treatment of many aneurysms not treatable by coils alone.
F1


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Dexamethasone helps outcome in hemorrhagic stroke patients

9:56 AM Posted by Dr Subhash Kumar, MBBS, MD, DM


There has always been a debate whether steroids are beneficial in management of hemorrhagic stroke with many neurologists not favoring it citing lack of clinical evidence even though there has been enough basic research. Now a large blinded study comparing a large group of patients in two centers have been made available and clearly shows clinical benefits of dexamethasone.

A Comparison of Acute Hemorrhagic Stroke Outcomes in 2 Populations

The Crete–Boston Study

  1. Ioannis Zaganas, MD, PhD;
  2. Amy P. Halpin, BS;
  3. Alexandra Oleinik, BA;
  4. Athanasios Alegakis, PhD;
  5. Dimitra Kotzamani, MD;
  6. Spiros Zafiris, MD;
  7. Chryssanthi Chlapoutaki, MD;
  8. Dimitris Tsimoulis, MD;
  9. Emmanouil Giannakoudakis, MD;
  10. Nikolaos Chochlidakis, MD;
  11. Aikaterini Ntailiani, MD;
  12. Christina Valatsou, MD;
  13. Efrosini Papadaki, MD, PhD;
  14. Antonios Vakis, MD, PhD;
  15. Karen L. Furie, MD;
  16. Steven M. Greenberg, MD, PhD;
  17. Andreas Plaitakis, MD, PhD

From the Neurology (I.Z., D.K., S.Z., C.C., D.T., E.G., A.P.), Toxicology (A.A.), Neurosurgery (N.C., A.V.), and Radiology (A.N., C.V., E.P.), Departments, University Hospital of Heraklion, Crete, Greece; and the Stroke Service (A.P.H., A.O., K.L.F., S.M.G.), Massachusetts General Hospital, Boston, MA.
  1. Correspondence to Andreas Plaitakis, MD, PhD, Professor and Chairman,Department of Neurology, University Hospital of Heraklion, Voutes, 71021, Heraklion, Crete, Greece. E-mail plaitakis@yahoo.com

Abstract

Background and Purpose—Although corticosteroid use in acute hemorrhagic stroke is not widely adopted, management with intravenous dexamethasone has been standard of care at the University Hospital of Heraklion, Crete with observed outcomes superior to those reported in the literature. To explore this further, we conducted a retrospective, multivariable-adjusted 2-center study.
Methods—We studied 391 acute hemorrhagic stroke cases admitted to the University Hospital of Heraklion, Crete between January 1997 and July 2010 and compared them with 510 acute hemorrhagic stroke cases admitted to Massachusetts General Hospital, Boston, from January 2003 to September 2009. Of the Cretan cases, 340 received a tapering scheme of intravenous dexamethasone, starting with 16 to 32 mg/day, whereas the Boston patients were managed without steroids.
Results—The 2 cohorts had comparable demographics and stroke severity on admission, although anticoagulation was more frequent in Boston. The in-hospital mortality was significantly lower on Crete (23.8%, n=340) than in Boston (38.0%, n=510; P<0.001) as was the 30-day mortality (Crete: 25.4%, n=307; Boston: 39.4%, n=510; P<0.001). Exclusion of patients on anticoagulants showed even greater differences (30-day mortality: Crete 20.8%; n=259; Boston 37.0%; n=359;P<0.001). The improved survival on Crete was observed 3 days after initiation of intravenous dexamethasone and was pronounced for deep-seated hemorrhages. After adjusting for acute hemorrhagic stroke volume/location, Glasgow Coma Scale, hypertension, diabetes mellitus, smoking, coronary artery disease and statin, antiplatelet, and anticoagulant use, intravenous dexamethasone treatment was associated with better functional outcomes and significantly lower risk of death at 30 days (OR, 0.357; 95% CI, 0.174–0.732).
Conclusions—This study suggests that intravenous dexamethasone improves outcome in acute hemorrhagic stroke and supports a randomized clinical trial using this approach.

http://stroke.ahajournals.org/content/early/2011/10/19/STROKEAHA.111.632174.abstract


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