Superior Hypophyseal Artery Aneurysms Have the Lowest Recurrence Rate with Endovascular Therapy
Superior Hypophyseal Artery Aneurysms Have the Lowest Recurrence Rate with Endovascular Therapy
N. Chalouhi et al
Abstract
BACKGROUND AND PURPOSE: Given the challenges posed by surgical clipping, endovascular techniques have been increasingly used to treat SHA aneurysms. The purpose of this study was to assess the safety and efficacy of endovascular techniques in the treatment of SHA aneurysms.
MATERIALS AND METHODS: Medical charts and initial and follow-up angiograms were reviewed retrospectively for all patients treated with endovascular procedures at our institution between January 2006 and February 2011.
RESULTS: We identified 87 patients with SHA aneurysms who were treated with endovascular techniques. Of these patients, 79 were women and only 8 were men (90.8% female predominance). Thirty-five patients were treated with coil embolization; 45, with stent-assisted coiling; 4, with balloon-assisted coil embolization; and 3, with a flow-diversion technique. Minor complications occurred in 2 patients (2.2%). None of the patients had a major complication. The mortality and permanent morbidity rates related to the procedure were 0%. Imaging follow-up was available for 89.4% of patients (DSA in 65, MRA in 11 patients) at a mean time point of 10.4 months (range, 6–60 months). Of the 76 patients with available follow-up, 3 patients had a recurrence (3.9%) and only 1 required further intervention (1.3%). Stent-assisted coiling was associated with lower recurrence rates than simple coil embolization.
CONCLUSIONS: SHA aneurysms have the lowest recurrence rate with endovascular treatment compared with aneurysms in other locations by using historical data. Because of its safety and efficacy, endovascular therapy should be considered the procedure of choice for the treatment of SHA aneurysms.
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Pre-intervention triage incorporating perfusion imaging improves outcomes in patients undergoing endovascular stroke therapy: a comparison with the device trials
http://jnis.bmj.com/content/early/2012/02/17/neurintsurg-2011-010189.short
Pre-intervention triage incorporating perfusion imaging improves outcomes in patients undergoing endovascular stroke therapy: a comparison with the device trials
Abstract
Objectives
Endovascular therapy of acute ischemic stroke is evolving towards
thrombectomy devices for vessel recanalization. High rates
of revascularization have been
reported in stroke device trials. However, the discrepancy between
recanalization and outcomes
raises the question whether patients
with irreversible ischemic injury are being exposed to these
interventions. This study
evaluated a triage methodology that
incorporates perfusion imaging against previous device trials that
treated all patients
within a certain time frame.
Methods 99
consecutive patients were identified with anterior circulation strokes
who had undergone endovascular therapy. All patients
had a baseline NIHSS score ≥8 and
had undergone pre-intervention CT perfusion. Rates of recanalization and
functional outcomes
were compared with the MERCI,
Multi-MERCI and Penumbra trials.
Results
This study's recanalization rate of 55.6% is not significantly different
from the 46% for MERCI (p=0.15) and 68% for Multi-MERCI
(p=0.08) but was significantly lower
than the 82% for the Penumbra trial (p<0.0001). Successfully
recanalized patients had
a significantly higher good outcome
of 67% in this cohort versus 46% in MERCI, 49% in Multi-MERCI and 29% in
Penumbra. The
rate of futile recanalization was
33% compared with 54% for MERCI, 51% for Multi-MERCI and 71% for
Penumbra. A small cerebral
blood volume (CBV) abnormality
(p<0.0001) and large mean transit time–CBV mismatch (p<0.0001)
were strong predictors of a
good outcome.
Conclusion
Despite similar or lower recanalization rates, there was a
significantly higher rate of good outcomes in the recanalized
population and thus a significantly
lower rate of futile recanalization in this study versus the device
trials, suggesting
a role for pre-intervention
perfusion imaging for patient selection.
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Dont use a lot of contrast!
It has been known that contrast is neurotoxic and my teachers have always told me to use less as far as possible
A recent article nicely shows the same....
http://stroke.ahajournals.org/content/39/12/3283.full
Microcatheter Contrast Injections During Intra-Arterial Thrombolysis May Increase Intracranial Hemorrhage Risk
Pooja Khari et al
Abstract
Background and Purpose—
During intra-arterial revascularization, either guide catheter
injections of contrast in the neck or microcatheter contrast
injections (MCIs) at or beyond the site of an
occlusion, can be used to visualize intracranial vasculature.
Neurointerventionalists
vary widely in their use of MCIs for a given
circumstance. We tested the hypothesis that MCIs are a risk factor for
intracranial
hemorrhage (ICH) in the Interventional
Management of Stroke (IMS) I and II trials of combined intravenous/IA
recombinant tissue
plasminogen activator therapy.
Methods— All
arteriograms with M1, M2, and ICA terminus occlusions were reanalyzed
(n=98). The number of MCIs within or distal to
the target occlusion was assigned. Postprocedure
CTs were reviewed for contrast extravasation and ICH. Contrast
extravasation
was defined as a hyperdensity suggestive of
contrast (Hounsfield unit >90) seen at 24 hours or present before 24
hours and
persisting or replaced by ICH at 24 hours.
Results— In this IMS subset, the rate of any ICH was 58% (57 of 98). More MCIs were seen in the ICH group (median=2 versus 1; P=0.04). Increased MCIs were associated with higher ICH rates (P=0.03). MCIs remained associated with ICH in multivariable analysis (P=0.01)
as did baseline CT edema/mass effect, atrial fibrillation, time to
intravenous recombinant tissue plasminogen activator
initiation, and Thrombolysis in Cerebral
Infarction reperfusion score. MCIs were also associated with contrast
extravasation
in unadjusted and adjusted analyses.
Conclusions—
MCIs may risk ICH in the setting of combined intravenous/intra-arterial
recombinant tissue plasminogen activator therapy,
possibly due to contrast toxicity or pressure
transmission by injections. MCIs should be minimized whenever possible.
These
findings will be tested prospectively in the IMS
III trial.
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Hemorrhagic Risk of Recent Silent Cerebral Infarct on Prethrombolysis MR Imaging in Acute Stroke
BACKGROUND AND PURPOSE: EIH is a rare complication after thrombolysis in patients with acute stroke, occurring in brain regions without visible ischemic change on pretreatment imaging. RSCIs can be detected by multimodal MR imaging and might be associated with an increased risk of HT postthrombolysis, related to BBBD. We aimed to assess the incidence of RSCI on pretreatment MR imaging and the subsequent risk of HT within RSCI areas on follow-up CT performed <36 hours after rtPA administration and on additional cerebral imaging before patient discharge.
MATERIALS AND METHODS: Pretreatment MR imaging was retrospectively analyzed from consecutive patients with stroke who received intravenous or intra-arterial rtPA for 2 years. RSCI was defined on MR imaging as a parenchymal area markedly hyperintense on FLAIR, different from the hyperacute infarct, and mildly-to-markedly hyperintense on DWI or enhanced on postgadolinium T1WI imaging.
RESULTS: Eighty-six patients with a median age of 66 years and a median NIHSS score on admission of 15 were studied; 66.3% received rtPA intravenously. The presence of RSCI was identified in 10 patients (11.6%) and was associated with large-vessel-disease etiology (40% versus 5.3%, P < .001) on univariate analysis. No HT was identified within the RSCI areas on any follow-up cerebral imaging.
CONCLUSIONS: These preliminary results require validation but suggest that small RSCIs are rather frequent and might not pose a higher risk of postthrombolysis HT.
MATERIALS AND METHODS: Pretreatment MR imaging was retrospectively analyzed from consecutive patients with stroke who received intravenous or intra-arterial rtPA for 2 years. RSCI was defined on MR imaging as a parenchymal area markedly hyperintense on FLAIR, different from the hyperacute infarct, and mildly-to-markedly hyperintense on DWI or enhanced on postgadolinium T1WI imaging.
RESULTS: Eighty-six patients with a median age of 66 years and a median NIHSS score on admission of 15 were studied; 66.3% received rtPA intravenously. The presence of RSCI was identified in 10 patients (11.6%) and was associated with large-vessel-disease etiology (40% versus 5.3%, P < .001) on univariate analysis. No HT was identified within the RSCI areas on any follow-up cerebral imaging.
CONCLUSIONS: These preliminary results require validation but suggest that small RSCIs are rather frequent and might not pose a higher risk of postthrombolysis HT.
ABBREVIATIONS:
- BBBD: blood-brain-barrier disruption
- ECASS: European Cooperative Acute Stroke Study
- EIH: extraischemic hemorrhage
- FFE:fast-field echo
- HI: hemorrhagic infarction
- HT:hemorrhagic transformation
- IQR:interquartile range
- IS: ischemic stroke
- PH: parenchymal hemorrhage
- RSCI: recent silent cerebral infarct
- SE: spin-echo
- SICH: symptomatic intracerebral hemorrhage
- TOAST:Trial of Org 10172 in Acute Stroke Treatment
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