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
Pre-intervention triage incorporating perfusion imaging improves outcomes in patients undergoing endovascular stroke therapy: a comparison with the device trials
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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
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Hemorrhagic Risk of Recent Silent Cerebral Infarct on Prethrombolysis MR Imaging in Acute Stroke
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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Endovascular Treatment of Ruptured Brain AVMs in the Acute Phase of Hemorrhage [INTERVENTIONAL]
Endovascular Treatment of Ruptured Brain AVMs in the Acute Phase of Hemorrhage [INTERVENTIONAL]
Patients with ruptured brain AVMs are at considerable risk of repeat hemorrhage, particularly when associated intranidal or flow-related aneurysms are present. There is controversy about the timing of diagnosis and treatment of patients with hemorrhagic stroke. We present our results of endovascular treatment of ruptured AVMs in the acute phase.
MATERIALS AND METHODS:Between January 2008 and March 2011, 23 patients (16 men, 7 women; mean age 42 years) with AVM-related hemorrhagic stroke were treated with endovascular techniques within 10 days of the ictus. There were 10 micro-AVMs (< 1 cm) and 1 single-hole pial fistula. In 9 patients, an intranidal or flow-related aneurysm was the likely cause of hemorrhage.
RESULTS:Complete obliteration of the AVM with Onyx was achieved in 13 of 23 patients (57%). Eight of the 13 AVMs were micro-AVMs and 3 had an intranidal aneurysm. Partial obliteration of the AVM was achieved in 10 of 23 patients (43%). In 6 of these 10 patients, an intranidal (n = 1) or flow-related aneurysm (n = 5) was obliterated with Onyx or coils. There were no complications of treatment. During a mean follow-up of 21 months in 22 surviving patients, no repeat hemorrhage occurred.
CONCLUSIONS:Endovascular treatment with Onyx in the acute phase cured most ruptured AVMs. All 9 AVM-associated aneurysms that were considered the source of hemorrhage could be excluded from the circulation. In patients with AVM-related hemorrhagic stroke, prompt angiographic diagnosis and treatment may improve prognosis by reducing repeat hemorrhage rate.
http://www.ajnr.org/content/early/2012/01/26/ajnr.A2995.abstract
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Multimodal Reperfusion Therapy for Large Hemispheric Infarcts in Octogenarians: Is Good Outcome a Realistic Goal?
Multimodal Reperfusion Therapy for Large Hemispheric Infarcts in Octogenarians: Is Good Outcome a Realistic Goal?
Abstract
BACKGROUND AND PURPOSE: MMRT may be beneficial in a subset of patients with large hemispheric stroke who cannot be treated with systemic thrombolysis. Because most previous studies only included relatively young patients, the outcome of very old patients given MMRT remains unknown.
MATERIALS AND METHODS: Consecutive patients with large hemispheric stroke treated with MMRT and admitted to intensive care were included. We compared neurologic and functional outcomes between patients younger and older than 80 years.
RESULTS: We included 14 patients older than 80 years and compared them with 66 patients who were younger than 80. Cerebrovascular risk factor profile, admission NIHSS scores, stroke etiology and pathogenesis, and procedure-related variables did not differ between the groups except for a higher prevalence of smoking in younger patients. Excellent target vessel recanalization (Thrombolysis in Myocardial Infarction score of 3) and good outcome at 90 days (modified Rankin Score ≤2) were more common in younger patients (45% versus 14%, P = .047, and 41% versus 0%, P = .008, respectively). In contrast, mortality rates were higher in octogenarians (43% versus 17%, respectively).
CONCLUSIONS: In this study, very old patients had higher chances of mortality and a very low probability of achieving functional independence even after MMRT. Further prospective studies are needed to examine the futility of MMRT in the very old.
Abbreviations
- GP IIb/IIIa
- glycoprotein IIb/IIIa
- IA
- intra-arterial
- MMRT
- multimodal reperfusion therapy
- TIMI
- Thrombolysis in Myocardial Infarction
- TOAST
- Trial of ORG 10172 in Acute Stroke
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Interobserver Reliability of Baseline Noncontrast CT Alberta Stroke Program Early CT Score for Intra-Arterial Stroke Treatment Selection [BRAIN]
- A.C. Gupta,
- P.W. Schaefer,
- Z.A. Chaudhry,
- T.M. Leslie-Mazwi,
- R.V. Chandra,
- R.G. González,
- J.A. Hirsch and
- A.J. Yoo
Early ischemic changes on pretreatment NCCT quantified using ASPECTS have been demonstrated to predict outcomes after IAT. We sought to determine the interobserver reliability of ASPECTS for patients with AIS with PAO and to determine whether pretreatment ASPECTS dichotomized at 7 would demonstrate at least substantial agreement.
MATERIALS AND METHODS:From our prospective IAT data base, we identified consecutive patients with anterior circulation PAO who underwent IAT over a 6-year period. Only those with an evaluable pretreatment NCCT were included. ASPECTS was graded independently by 2 experienced readers. Interrater agreement was assessed for total ASPECTS, dichotomized ASPECTS (≤7 versus >7), and each ASPECTS region. Statistical analysis included determination of Cohen coefficients and concordance correlation coefficients. PABAK coefficients were also calculated.
RESULTS:One hundred fifty-five patients met our study criteria. Median pretreatment ASPECTS was 8 (interquartile range 7–9). Interrater agreement for total ASPECTS was substantial (concordance correlation coefficient = 0.77). The mean ASPECTS difference between readers was 0.2 (95% confidence interval, –2.8 to 2.4). For dichotomized ASPECTS, there was a 76.8% (119/155) observed rate of agreement, with a moderate = 0.53 (PABAK = 0.54). By region, agreement was worst in the internal capsule and the cortical areas, ranging from fair to moderate. After adjusting for prevalence and bias, agreement improved to substantial or near perfect in most regions.
CONCLUSIONS:Interobserver reliability is substantial for total ASPECTS but is only moderate for ASPECTS dichotomized at 7. This may limit the utility of dichotomized ASPECTS for IAT selection.
http://www.ajnr.org/content/early/2012/02/09/ajnr.A2942.abstract
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Recanalization with Wingspan Stent for Acute Middle Cerebral Artery Occlusion in Failure or Contraindication to Intravenous Thrombolysis: A Feasibility Study [INTERVENTIONAL]
Recanalization with the Wingspan stent, which can be deployed rapidly and safely, is an option for treating acute ischemic stroke when intravenous thrombolysis has failed or is contraindicated. This study was performed to evaluate feasibility, efficacy, and safety of recanalization for acute middle cerebral artery occlusion using the Wingspan stent.
MATERIALS AND METHODS:We collected 10 patients with acute MCA occlusion in whom recanalization was not achieved with a standard intravenous thrombolysis, or who were ineligible for intravenous thrombolysis, or who presented after 3 hours of symptom onset and in whom the stent placement could be completed within 8 hours from symptom onset. We analyzed angiographic and clinical results.
RESULTS:Successful recanalization with the Wingspan stent was achieved in all patients. The mean NIHSS score on admission was 12.7 points (range 4–21). The occlusion sites were located in the 1st segment (n = 7; 2 left, 5 right) and 2nd segment (n = 3, all right) of the MCA. The mean time interval from stroke symptom onset to stent placement was 344.8 ± 76.3 minutes. No intracranial hemorrhage, vessel perforations, or dissections occurred in any patient. Nine patients improved on the NIHSS at 7 days. One patient did not have a change in the NIHSS score, even though the occluded artery was completely recanalized. At 7 days, the NIHSS score of all patients was 4.4 ± 4.7 (median 4, range 0–13). At discharge, an mRS of ≤3 was achieved in all patients and an mRS of ≤2 was achieved in 7 patients (70%).
CONCLUSIONS:This small case series demonstrates the feasibility of using the Wingspan stent safely and effectively for MCA occlusions when standard treatments are ineffective or not available.
http://www.ajnr.org/content/early/2012/02/09/ajnr.A2996.abstract
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Incomplete mechanical recanalization of middle cerebral artery occlusions facilitates endogenous recanalization within 5 h
Incomplete mechanical recanalization of middle cerebral artery occlusions facilitates endogenous recanalization within 5 h
Background and purpose
Successful revascularization can often improve functional outcome after large intracranial arterial occlusions. However, incomplete or unsuccessful recanalization is often the end result after attempted mechanical thrombectomy. A study was undertaken to determine whether partial recanalization of proximal isolated middle cerebral artery (MCA) occlusions facilitates endogenous thrombolysis and spontaneous recanalization.
MethodsWe retrospectively analyzed consecutive patients with acute ischemic stroke undergoing mechanical thrombectomy using the Merci Retriever System for occlusions involving any portion of the M1 segment of the MCA. Only those patients with a residual obstruction of the proximal MCA segments were included. The rates of facilitated endogenous recanalization (FER5) by imaging within the 5 h following intervention were compared in patients with partial proximal recanalization and those in whom recanalization was unsuccessful.
ResultsForty-two patients were included in the analysis. Twenty-six patients had good recanalization of the proximal aspect of the target lesion with an arterial occlusive lesion score of 2 or 3 but a residual partial or total occlusion of the MCA, while 16 patients failed to recanalize any portion of the target occlusion. Twelve patients (46%) in the first group and only one (5.9%) in the second group had facilitated endogenous recanalization on interval imaging 5 h after intervention (OR 12.9, 95% CI 1.5 to 112.2). Nine patients with proximal recanalization had good clinical outcomes at discharge (mRS ≤2) compared with none without recanalization (p=0.01), but FER did not have a relationship with clinical outcome.
ConclusionsDespite initially incomplete proximal mechanical thrombectomy, nearly half of all patients with residual M1 occlusions will undergo further endogenous recanalization within the subsequent 5 h.
http://jnis.bmj.com/content/early/2012/02/06/neurintsurg-2011-010207.short
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