Acute stroke treatment: without time limitations

2:26 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Since last forever, much to my chagrin, the concept of TIME IS BRAIN has lingered on and hampered the treatment of stroke patients. From the year 1 of my neuroradioogy, i.e my training days, I believed the insufficiencies hidden in this concept but no one believes me. Now however, concepts are improving and even nonradiologists are understanding the benefits of advanced noninvasive imaging. Proof is the multitude of papers published on the usage of perfusion imaging to assess for suitability of treatment of acute stroke.

Now perfusion imaging is being taken to the next level and applied to patients with acute stroke > 6 hours, patients which earlier were destined to live and die with 'aspirin' and 'heparin' nad not get the benefit of aggressive management.

Turk et al have orated an abstract in the SNIS annual meet where they used perfusion imaging in patients beyond 6 hours and patients under 6 hours and found no difference in outcome.

Go through the article and enlighten. Yipee!

J NeuroIntervent Surg 2010;2:A1 doi:10.1136/jnis.2010.003244.2

SNIS 7th Annual Meeting

Oral abstract

Acute stroke treatment: without time limitations

A Turk III,R Turner,I Chaudry

Medical University of South Carolina, Charleston, South Carolina, USA

Abstract

Background Many new stroke trials are evaluating the utility of perfusion imaging for patient selection within certain time constraints. There is evidence that patients with a delayed (>12 h) clinical–diffusion mismatch have poor clinical outcomes. We present our experience utilizing perfusion imaging to triage patients for endovascular therapy irrespective of time constraints.

Methods 53 patients were treated over the past 2 years utilizing presenting National Institutes of Health Stroke Scale (NIHSS), anatomic imaging and perfusion information. Patients were excluded if they had a hemorrhage or significant completed stroke (>1/3 middle cerebral artery territory volume) on CT or cerebral blood volume maps. If perfusion imaging was limited, as in some basilar occlusion cases, then the clinical examination (NIHSS) was used. The median time to treatment from symptom onset of the patient cohort was then determined and patients were divided into two groups. Clinical outcomes were then documented and subgroup analysis was performed.

Results The mean time to treatment was 10.36 h and the median was 6.13 h (range 1.75–72 h), suggesting several patients were treated far beyond 6 h. Utilizing a 6 h time point to identify two separate groups yielded 26 patients treated before 6 h and 27 patients treated more than 6 h from symptom onset. Angiographically, TIMI2 or better flow was restored 96% of the time. Patient outcomes in those treated less than 6 h compared with more than 6 h showed modified Rankin Score (mRS) of 0–2 in 36% and 37%, respectively, and mRS 0–3 in 56% and 52%, respectively.

Conclusion Utilization of perfusion based techniques is a viable clinical strategy for identifying acute stroke patients for endovascular therapy. Clinical outcomes can be obtained that are similar to those of clinical trials, irrespective of time constraints in appropriately selected patients.

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Case Example: Basilar Artery Dissecting Aneurysm Treated by Flow Diversion with Enterprise stent only

3:54 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

This is the case of a 31 years old patient.

The patient had long segment dissection of the basilar artery with a small, wide necked pseudoaneurysm on the distal segment.

As she was symptomatic, we decided to treat her.

In this situation, the only real option was to stent it and we did so.

An Enterprise stent was deployed without any difficulty.

The immediate post procedure control showed some wall smoothening as well as morphology change in the pseudoaneurysm and the parent artery.

The patient was put on dual antiplatelets and a check angiogram done after 6 months.

The was complete remodelling of the basilar artery with smooth walls and disappearance of the pseudoaneurysm. The artery had straightened and widened to some extent also.

The patient has been clinically asymptomatic since the procedure –almost 2 years now.

Fig 1: Vertebral angiogram showing the basilar artery dissection with pseudoaneurysm involving almost the entire length of the vessel

Fig 2: Post stenting vertebral angiogram showing some vessel straightening, wall smoothening and shaper change of the pseudosac; although the changes are not very prominent at this point of time

Fig 3: 6 month follow up check vertebral angiogram showing the completely remodelled artery with totally smooth wall and no visualisation of the pseudoaneurysm. The basilar artery looks somewhat larger calibre than the native artery though.

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Case Example: Flow Diversion Treatment for Internal Carotid Artery Blister Aneurysm with Enterprise Stent

7:33 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

This is the case of a young adult, previously medically fit, presenting with acute subarachnoid haemorrhage (Hunt and Hess Grade I).
A cerebral DSA showed a tiny blister from the posteromedial wall of the right internal carotid artery. The aneurysm was so small and the location so unusual that coiling or surgery was not possible in this case.
Hence treatment with flow diversion was decided upon.
We used a single Enterprise stent for this purpose.
Immediate post stent angiogram showed some conformational change in the parent artery as well as some change in the morphology of the aneurysm as well.
The patient was put on dual antiplatelets and advised rest.
After 8 months a check angiogram was done in which the aneurysm was completely excluded from circulation. The parent vessel was fully patent with normal distal perfusion.

Fig 1: RICA injection showing the small aneurysm (arrow)

Fig 2: Immediate post stenting control: the arrowheads point to the stent markers, note the straightening of the ICA and MCA with loss of the curve between the MCA and ICA, the aneurysm has decreased in size and poorly filling now, only a tiny jet on contrast is seen to come out of the stent and fill a small portion of the blister

Fig 3. 8 months follow up image; there is further flow modification resulting in further straightening of the artery, poor flow into the ACA and complete exclusion of the aneurysm.

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Flow Diversion for Aneurysms

11:15 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

What is flow diversion therapy of intracranial aneurysms?

The endovascular treatment of intracranial aneurysms has rapidly evolved during the past 2 decades. However, our ability to achieve a durable and complete occlusion of aneurysms remains, in some cases, limited especially large and wide-necked or blister aneurysms.

During the past 3-4 years, a new generation of endovascular devices—the flow diverters—has been developed. These are essentially stents designed to reconstruct the parent artery and divert blood flow along the normal anatomical course of the vessel and away from the aneurysm neck. Complete aneurysm occlusion is not achieved at the time of the procedure. There is slow progressive thrombosis and the stent provides a scaffolding over which endothelium grows to ultimately seal off the aneurysm.

What are the different stents used?

There are two stents specifically made for flow diversion: SILK and PIPELINE.

However, ENTERPRISE or SOLITAIRE stents which are usually used for stent assisted coiling of aneurysms can also be used and can be effective in certain situations.

Is the treatment established

The PIPELINE device is currently an investigational device in the United States, which is only available within the context of ongoing US Food and Drug Administration (FDA) clinical trials.

It has received CE Mark approval in Europe on the basis of the Pipeline Embolization Device in the Intracranial Treatment of Aneurysms (PITA) study.

In addition, Dr. Pedro Lylyk in Argentina an Dr Saruhan Cekirge from Turkey have continued to treat patients under individual compassionate use provisions.

The Silk stent (Balt Extrusion, Montmorency, France) is a braided, self-expanding, high metal surface area coverage construct that also has CE Mark approval in Europe for the treatment of intracranial aneurysms. Other similar flow-diverting constructs are at earlier stages of development and are currently without published clinical data.

However, it is important to acknowledge that flow-diversion technology is at a very early stage, and in the Unites States, the PED remains an investigational device. As such, the available data do not provide a sufficient foundation on which to make firm recommendations regarding patient selection.

The PIPELINE stent

See three case examples below and an animation of the PIPELINE stent being used.

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Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery

8:06 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Most coronary angiographers look at the carotids and vertebrals as well as the renal arteries also while doing coronary angiography on the pretext that these patients may have coexistent disease and may require treatment of these conditions prior to treating the corronary stenosis.

Similarly, most cardiac surgeons advice carotid endarterectomy or stenting prior to CABG for patients with significant carotid stenosis even if they are asymptomatic.

I have always doubted this policy and now there is a proof.

The authors of this paper must be congratulated for bucking the trend and proving that these patients these poor patients need not undergo another invasive and potentially fatal procedure unncessarily.

by Mahmoudi, M., Hill, P. C., Xue, Z., Torguson, R., Ali, G., Boyce, S. W., Bafi, A. S., Corso, P. J., Waksman, R.

Stroke 2011

Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery

Background and Purpose—

Stroke development is a major concern in patients undergoing coronary artery bypass grafting (CABG). Whether asymptomatic severe carotid artery stenosis (CAS) contributes to the development of stroke and mortality in such patients remains uncertain.

Methods—

A retrospective analysis of 878 consecutive patients with documented carotid duplex ultrasound who underwent isolated CABG in our institution from January 2003 to December 2009 was performed. Patients with severe CAS (n=117) were compared with those without severe CAS (n=761) to assess the rates of stroke and mortality during hospitalization for CABG. The 30-day mortality rate was also assessed.

Results—

Patients with severe CAS were older and had a higher prevalence of peripheral arterial disease and heart failure. Patients with severe CAS had similar rates of in-hospital stroke (3.4% versus 3.6%; P=1.0) and mortality (3.4% versus 4.2%; P=1.0) compared with patients without severe CAS. The 30-day rate of mortality was also similar between the 2 cohorts (3.4% versus 2.9%; P=0.51).

Conclusions—

Severe CAS alone is not a risk factor for stroke or mortality in patients undergoing CABG. The decision to perform carotid imaging and subsequent revascularization in association with CABG must be individualized and based on clinical judgment.

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Rupture of a cerebral aneurysm following carotid endarterectomy

5:52 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Rupture of a cerebral aneurysm following carotid endarterectomy

by Siddiqui, A., Vora, N., Edgell, R. C., Callison, R. C., Kitchener, J., Alshekhlee, A.

J NeuroIntervent Surg

doi:10.1136/neurintsurg-2011-010091

Following carotid revascularization with either carotid endarterectomy or stenting, the impaired cerebral autoregulation can lead to cerebral hyperperfusion syndrome. This impaired autoregulation and increased flow may also put patients with unruptured aneurysms at risk for subarachnoid hemorrhage in the perioperative period. A patient is reported who underwent carotid endarterectomy for symptomatic carotid stenosis. A small anterior communicating artery aneurysm was identified preoperatively, which ruptured 2 days after carotid endarterectomy. Screening for cerebral aneurysms prior to carotid revascularization will allow operators to minimize this risk, either through prior treatment of the aneurysm or tight blood pressure control in the perioperative period.

We do occasionally see intracranial aneurysms associated with carotid artery stenosis.

And, we leave then alone....while reopening the stenosis.

However, this case shows that this approach is not without vice...

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Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections

8:32 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

This study to date is the largest registry of the flow diversion devices: PIPELINE or SILK.
The authors, here too, like all other smaller studies, have said that the complication rates are acceptable.
This study had 6 major complications in the 90 aneurysms followed up, only 52% had complete occlusion, 66% needed multiple stents which are exorbitantly costly...wonder what the definition of 'acceptable complication rate' is...which most of these studies say...no doubt industry sponsored.
But where ever feasible why not do a parent vessel sacrifice, which is much more safe, durable and cheap...or...use stent grafts/enterprise stent which are much cheaper than the flow diverters..

Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections:

Abstract

Introduction

The purpose of this study was to evaluate the safety and efficacy of the recently available flow diverter “pipeline embolization
device” (PED) for the treatment of intracranial aneurysms and dissections.

Methods

Eighty-eight consecutive patients underwent an endovascular treatment of 101 intracranial aneurysms or dissections using the
PED between September 2009 and January 2011. The targeted vessels include 79 (78%) in the anterior circulation and 22 (22%)
in the posterior circulation. We treated 96 aneurysms and 5 vessel dissections. Multiple devices were implanted in 67 lesions
(66%).

Results

One technical failure of the procedure was encountered. Immediate exclusion of the target lesion was not observed. Angiographic
follow-up examinations were carried out in 80 patients (91%) with 90 lesions and revealed complete cure of the target lesion(s)
in 47 (52%), morphological improvement in 32 lesions (36%), and no improvement in 11 lesions (12%). Six major complications
were encountered: one fatal aneurysm rupture, one acute and one delayed PED thrombosis, and three hemorrhages in the dependent
brain parenchyma.

Conclusion

Our experience reveals that the PED procedure is technically straightforward for the treatment of selected wide-necked saccular
aneurysms, fusiform aneurysms, remnants of aneurysms, aneurysms with a high likelihood of failure with conventional endovascular
techniques, and dissected vessels. While vessel reconstruction, performed after dissection, is achieved within days, remodeling
of aneurysmal dilatations may take several months. Dual platelet inhibition is obligatory. Parenchymal bleeding into brain
areas dependent on the target vessel is uncommon.

DOI 10.1007/s00234-011-0948-x

Authors
- Sebastian Fischer, Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Zsolt Vajda, Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Marta Aguilar Perez, Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Elisabeth Schmid, Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Nikolai Hopf, Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Hansjörg Bäzner, Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Hans Henkes, Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany

Journal Neuroradiology
Online ISSN 1432-1920
Print ISSN 0028-3940

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Treatment of intracranial aneurysms. Reconstruction of the parent artery with flow-diverting (Silk) stent

8:25 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Treatment of intracranial aneurysms. Reconstruction of the parent artery with flow-diverting (Silk) stent:

Abstract

Introduction

Since the flow diverters (FDs) have been introduced it is possible to treat aneurysms that are considered difficult or impossible
to treat with usual endovascular or surgical methods. It is still uncertain which aneurysms are suitable for this new treatment.
We present the periprocedural complications, immediate result, late complications, imaging follow-up at 6 and 12 months and
clinical follow-up at 2–23 months.

Methods

Twenty-two patients with 26 wide-necked or blister-like aneurysms had 23 treatments with implantation of a Silk stent. Eleven
patients had re-canalizations, and 11 patients were either untreated or had been treated for another aneurysm.

Results

Periprocedural complications were seen in four treatments (17%). However, none of these had clinical consequences. Mortality
and morbidity rates were 1 of 22 (5%) and 1 of 22 (5%), respectively. Clinical outcome was unchanged in 16 patients (72%),
3 patients improved (14%) and 3 patients worsened (14%). The end-of-procedure angiography did not show complete occlusion
of any of the aneurysms, but at 6 months follow-up angiography, 17 of 25 aneurysms (68%) were completely occluded, and at
12 months, 18 of 21 aneurysms (86%) were occluded.

Conclusion

The effect of the Silk FD in terms of occlusion of the aneurysms seems to occur mainly during the first 6 months after placement
but continues during the following time. Most delayed complications occur immediately after discontinuing the anticoagulation
medication. Considering the complexity of the aneurysms treated, the rate of complications is acceptable.

Content Type Journal Article
Category Interventional Neuroradiology
Pages 1-10
DOI 10.1007/s00234-011-0949-9
Authors
- Aase Wagner, Department of Neuroradiology, University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Marie Cortsen, Department of Neuroradiology, University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- John Hauerberg, Department of Neurosurgery, University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Bertil Romner, Department of Neurosurgery, University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Mathias Pedersen Wagner, Department of Neuroradiology, University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark

Journal Neuroradiology
Online ISSN 1432-1920
Print ISSN 0028-3940

This is a small patient group who underwent flow diversion with the SILK stent. 1/22 died and 1/22 had clinical deficits. 18/22 aneurysms occluded at 1 year. I do not think these results are really very good

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The value of magnetic resonance imaging for the detection of the bleeding source in non-traumatic intracerebral haemorrhages: a comparison with conventional digital subtraction angiography

8:19 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Three cheers for non invasive imaging...

The value of magnetic resonance imaging for the detection of the bleeding source in non-traumatic intracerebral haemorrhages: a comparison with conventional digital subtraction angiography:

Abstract

Introduction

Conventional digital subtraction angiography (DSA) is currently regarded as the gold standard in detecting underlying vascular
pathologies in patients with intracerebral haemorrhages (ICH). However, the use of magnetic resonance imaging (MRI) in the
diagnostic workup of ICHs has considerably increased in recent years. Our aim was to evaluate the diagnostic accuracy and
yield of MRI for the detection of the underlying aetiology in ICH patients.

Methods

Sixty-seven consecutive patients with an acute ICH who underwent MRI (including magnetic resonance angiography (MRA) and DSA
during their diagnostic workup) were included in the study. Magnetic resonance images were retrospectively analysed by two
independent neuroradiologists to determine the localisation and cause of the ICH. DSA was used as a reference standard.

Results

In seven patients (10.4%), a DSA-positive vascular aetiology was present (one aneurysm, four arteriovenous malformations,
one dural arteriovenous fistula and one vasculitis). All of these cases were correctly diagnosed by both readers on MRI. In
addition, MRI revealed the following probable bleeding causes in 39 of the 60 DSA-negative patients: cerebral amyloid angiopathy
(17), cavernoma (9), arterial hypertension (8), haemorrhagic transformation of an ischaemic infarction (3) and malignant brain
tumour with secondary ICH (2).

Conclusion

Performing MRI with MRA proved to be an accurate diagnostic tool in detecting vascular malformations in patients with ICH.
In addition, MRI provided valuable information regarding DSA-negative ICH causes, and thus had a high diagnostic yield in
ICH patients.

Content Type Journal Article
Category Diagnostic Neuroradiology
Pages 1-8
DOI 10.1007/s00234-011-0953-0
Authors
- Nina Lummel, Department of Neuroradiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
- Jürgen Lutz, Department of Neuroradiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
- Hartmut Brückmann, Department of Neuroradiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
- Jennifer Linn, Department of Neuroradiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
Journal Neuroradiology
Online ISSN 1432-1920
Print ISSN 0028-3940

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Applicability of Tableside Flat Panel Detector CT Parenchymal Cerebral Blood Volume Measurement in Neurovascular Interventions: Preliminary Clinical Experience [INTERVENTIONAL]

1:07 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

P. Mordasini,M. El-Koussy,C. Brekenfeld,G. Schroth,U. Fischer,J. Beck,and J. Gralla. Applicability of Tableside Flat Panel Detector CT Parenchymal Cerebral Blood Volume Measurement in Neurovascular Interventions: Preliminary Clinical Experience AJNR Am J Neuroradiol 2011 originally published online on September 29, 2011, 10.3174/ajnr.A2715.

Applicability of Tableside Flat Panel Detector CT Parenchymal Cerebral Blood Volume Measurement in Neurovascular Interventions: Preliminary Clinical Experience [INTERVENTIONAL]:

BACKGROUND AND PURPOSE:

CBV is a vital perfusion parameter in estimating the viability of brain parenchyma (eg, in cases of ischemic stroke or after interventional vessel occlusion). Recent technologic advances allow parenchymal CBV imaging tableside in the angiography suite just before, during, or after an interventional procedure. The aim of this work was to analyze our preliminary clinical experience with this new imaging tool in different neurovascular interventions.

MATERIALS AND METHODS:

FPD-CBV measurement was performed on a biplane FPD angiographic system. Eighteen patients (11 women, 7 men) were examined (age range, 18–86 years; median, 58.7 years). In the 10 patients with stroke, the extent of intracranial hypoperfusion was evaluated. The remaining 8 patients had an intracranial hemorrhage; periprocedural CBV was evaluated during the course of interventional treatment.

RESULTS:

In the 18 cases studied, 23 CBV measurements were performed. Twenty acquisitions were of sufficient diagnostic quality. The remaining 3 acquisitions failed technically, 1 due to motion artifacts and 2 due to injection technique and/or hardware failure.

CONCLUSIONS:

FPD-CBV measurement in the angiography suite provides a feasible and helpful tool for peri-interventional neuroimaging. It extends the intraprocedural imaging modalities to the level of tissue perfusion. However, the technique has technical limitations and shows room for improvement in the future.

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