Long-Term Clinical and Imaging Follow-Up of Complex Intracranial Aneurysms Treated by Endovascular Parent Vessel Occlusion

2:43 PM Posted by Dr Subhash Kumar, MBBS, MD, DM


Long-Term Clinical and Imaging Follow-Up of Complex Intracranial Aneurysms Treated by Endovascular Parent Vessel Occlusion

  1. R.A. Willinsky
+Author Affiliations
  1. From the Department of Neurosurgery, Neurovascular & Stroke Programs (C.C.M.), Yale University School of Medicine, New Haven, Connecticut; Division of Neuroradiology, Department of Medical Imaging (Z.K., K.G.t.B., R.A.W.), Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada.
  1. Please address correspondence to Charles C. Matouk, Department of Neurosurgery, Neurovascular & Stroke Programs, Yale University School of Medicine, 333 Cedar St, TMP402, New Haven, CT, 06510; e-mail: charles.matouk@yale.edu

Abstract

BACKGROUND AND PURPOSE: Flow-diverting stents are increasingly being used for the treatment of complex intracranial aneurysms, but the indications for their use in lieu of traditional endovascular PVO have yet to be precisely defined. The purpose of this study was to review the clinical and imaging outcomes of patients with intracranial aneurysms treated by PVO.
MATERIALS AND METHODS: A total of 28 patients with intracranial aneurysms, treated by PVO between July 1992 and December 2009, were reviewed. Aneurysms arising from peripheral arteries were excluded. Clinical and imaging data were retrospectively analyzed from a prospectively maintained data base.
RESULTS: There were 28 patients with 28 aneurysms treated by PVO. Aneurysms of the anterior circulation presenting with mass effect (n = 11) or discovered incidentally (n = 1), and dissecting-type VB aneurysms presenting with subarachnoid hemorrhage (n = 6) faired the best with high obliteration rates (83.3% and 83.6%, respectively) and no permanent major ischemic complications. In contrast, VB aneurysms presenting with mass effect (n = 7) demonstrated the lowest obliteration rate (57.1%), the highest rate of permanent major ischemic complications (28.6%), and a high mortality rate (28.6%).
CONCLUSIONS: PVO is a safe and effective treatment for complex intracranial aneurysms of the carotid artery and dissecting-type VB aneurysms presenting with SAH. In contrast, PVO for aneurysms of the VB circulation presenting with mass effect is less efficacious and associated with significant morbidity and mortality. It is hoped that flow diverters may represent a better treatment technique for these most difficult-to-treat lesions.

Abbreviations

BTO
 
balloon test occlusion
 
ECIC
 
extracranial-intracranial
 
PCA
 
posterior cerebral artery
 
PVO
 
parent vessel occlusion
 
VA
 
vertebral artery
 
VB
 
vertebrobasilar
http://www.ajnr.org/content/early/2012/05/03/ajnr.A3079.abstract
Published online before print May 3, 2012,  doi: 10.3174/ajnr.A3079


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Incidence and outcome of procedural distal emboli using the Penumbra thrombectomy for acute stroke

3:23 PM Posted by Dr Subhash Kumar, MBBS, MD, DM



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Superior Hypophyseal Artery Aneurysms Have the Lowest Recurrence Rate with Endovascular Therapy

3:20 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

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

3:18 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

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

  1. Jeffrey Carpenter
 

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!

3:14 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 

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

2:49 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Hemorrhagic Risk of Recent Silent Cerebral Infarct on Prethrombolysis MR Imaging in Acute Stroke

by Gaillard, N., Schmidt, C., Costalat, V., Bousquet, J. P., Heroum, C., Milhaud, D., Bonafe, A., Arquizan, C.
 
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.

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
 
http://www.ajnr.org/content/33/2/227.abstract


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Endovascular Treatment of Ruptured Brain AVMs in the Acute Phase of Hemorrhage [INTERVENTIONAL]

12:48 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Endovascular Treatment of Ruptured Brain AVMs in the Acute Phase of Hemorrhage [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

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?

12:39 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Multimodal Reperfusion Therapy for Large Hemispheric Infarcts in Octogenarians: Is Good Outcome a Realistic Goal?

  1. D. Arkadir,
  2. R. Eichel,
  3. J.M. Gomori,
  4. T. Ben Hur,
  5. J.E. Cohen and
  6. R.R. Leker

  1. 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
    http://www.ajnr.org/content/early/2012/02/02/ajnr.A2916.abstract


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