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Kühn AL, de Macedo Rodrigues K, Singh J, Massari F, Puri AS. Distal radial access in the anatomical snuffbox for neurointerventions: a feasibility, safety, and proof-of-concept study. J Neurointerv Surg 2020; 12:798-801. [PMID: 31915209 DOI: 10.1136/neurintsurg-2019-015604] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/08/2019] [Accepted: 12/15/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To report the first use of distal radial artery (dRA) access for a variety of neurointerventions and to demonstrate the safety and feasibility of this approach. METHODS A retrospective review of our prospective neurointerventional database of endovascular interventions was conducted and, between May and October 2019, all patients in whom the intervention was performed via dRA in the anatomical snuffbox were identified. Patient demographics, clinical information, procedural and radiographic data were collected. RESULTS 48 patients with a mean age of 64.4 years (range 35-84 years) were included. 27 patients were female. dRA access was achieved in all cases. Conversion to femoral access was required in five cases (10.4%) due to tortuous vessel anatomy and limited support of the catheters in the aortic arch. Interventions performed included aneurysm treatment (with flow diverters, Woven EndoBridge device placement, coiling or stent-assisted coiling), arteriovenous malformation and dural arteriovenous fistula embolization, carotid artery stentings, stroke thrombectomy, thrombolysis for central retinal artery occlusion, intracranial stenting, middle meningeal artery embolization, vasospasm treatment, and spinal angiography with embolization. Radial artery vasospasm was seen in two cases and successfully treated with antispasmolytic medication. No symptomatic radial artery occlusion or ischemic event was observed. CONCLUSION dRA access is safe and effective for a variety of neurointerventions. Our preliminary experience with this approach is very promising and shows high patient satisfaction.
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Kühn AL, Gounis MJ, Puri AS. Introduction: History and Development of Flow Diverter Technology and Evolution. Neurosurgery 2019; 86:S3-S10. [DOI: 10.1093/neuros/nyz307] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/15/2019] [Indexed: 11/12/2022] Open
Abstract
AbstractThe introduction of flow diverter technology to the field of neurointervention has revolutionized the treatment of intracranial aneurysms. The therapy approach has shifted from intrasaccular aneurysm treatment to exclusion of the aneurysm from the blood circulation with remodeling of the parent artery. Previously, “difficult”-to-treat aneurysms including fusiform and blister aneurysms, but also aneurysms arising from a diseased vessel segment, can now be safely and permanently treated with flow diverters. A little over a decade ago, after extensive bench testing and refinement of the flow diverter concept, the device was eventually available for clinical use and today it has become a standard treatment for intracranial aneurysms. Currently, United States Food and Drug Administration (FDA)-approved flow diverters are the Pipeline Embolization Device (Medtronic) and the Surpass Streamline Flow Diverter (Stryker). The devices can either be delivered or deployed via a standard femoral artery approach or a radial artery approach. Other considerations for catheter setup and device deployment strategies depending on aneurysm location or vessel anatomy are described.
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De Macedo Rodrigues K, Kühn AL, Tamura T, Dabus G, Kan P, Marosfoi MG, Lozano JD, Perras M, Brooks C, Howk MC, Hou SY, Rex DE, Massari F, Gounis MJ, Wakhloo AK, Puri AS. Pipeline Embolization Device for Pericallosal Artery Aneurysms: A Retrospective Single Center Safety and Efficacy Study. Oper Neurosurg (Hagerstown) 2019; 14:351-358. [PMID: 28521024 DOI: 10.1093/ons/opx111] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 04/11/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pericallosal artery aneurysm treatment may be challenging using traditional endovascular techniques. OBJECTIVE To demonstrate the feasibility, efficacy, and safety of endovascular treatment of pericallosal artery aneurysm using flow diverters. METHODS We performed a retrospective review of our institutional database from July 2013 through July 2016 and identified 7 subjects with a pericallosal artery aneurysm treated with the Pipeline embolization device (ev3 Neurovascular, Medtronic, Dublin, Ireland) and at least 1 follow-up angiogram. Technical feasibility, procedural complication, angiographic results, and clinical outcome were evaluated. RESULTS Placement of the Pipeline embolization device was successful in all cases without evidence of procedural complication. Five out of 7 subjects showed a complete aneurysm occlusion at 6- to 12-mo follow-up angiogram. The 2 subjects with persistent aneurysm filling showed decreased aneurysm sac volume on follow-up angiograms (96% and 60%). There was no evidence of in-implant stenosis or intimal hyperplasia. No thromboembolic or hemorrhagic complications were seen during the follow-up period. Only 1 patient had a transient change in Modified Rankin scale score from baseline as a result of different unrelated procedure. CONCLUSION Our preliminary results demonstrate feasibility of the use of flow diverter stent for treatment of aneurysms of the pericallosal artery with rate of aneurysm occlusion comparable to literature and without evidence of increased procedural or short-term morbidity. A long-term and larger cohort study is needed to validate our findings.
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Kühn AL, Jalisi S, Nishino M, Ivanovic V. Biphenotypic sinonasal sarcoma – Description of radiologic, intraoperative and pathologic findings. OTOLARYNGOLOGY CASE REPORTS 2019. [DOI: 10.1016/j.xocr.2019.100113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Kühn AL, Kan P, Henninger N, Srinivasan V, de Macedo Rodrigues K, Wakhloo AK, Gounis MJ, Puri AS. Impact of age on cerebral aneurysm occlusion after flow diversion. J Clin Neurosci 2019; 65:23-27. [PMID: 31072739 DOI: 10.1016/j.jocn.2019.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/28/2019] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to evaluate safety and efficacy of the pipeline embolization device (PED) in different patient age groups with unruptured intracranial aneurysms (UIA). All patients with UIA treated with the PED between 2011 and 2017 were included. Based on their age, patients were trichotomized to: young (≤45 years), middle-aged (46 to <65 years) and older (≥65 years) groups. Patient's vascular risk factors, presenting symptoms and mRS on admission were collected. Follow-up imaging was evaluated for presence/absence of aneurysm occlusion. Clinical outcome at discharge, 3-9 months and 12-18 months was also documented when available. A total of 260 patients harboring 307 aneurysms (young = 57, middle-age = 144 and older age group = 64). Most aneurysms were located in the anterior circulation (94.8%). Overall morbidity and mortality was 2.3% each (6/260). At 3-9 months near complete to complete aneurysm occlusion was 82.5% (47/57) in the young age group, 82.6% (100/121) in the middle age, and 70.2% (40/57) in the older age group. At 12-18-month, near complete to complete occlusion was 100% in the young age group (32/32), 91.4% (64/70) in the middle age, and 78.4% (29/37) in the older age group. After adjustment for potential confounders, older age patients less frequently achieved near complete to complete occlusion by 3 years than younger subjects (p = 0.009, HR 1.34 95%, CI 1.08-1.66). Our results indicate feasibility and safety of PED across different age groups. Further study is required to determine age-related factors relating to aneurysm occlusion after PED to improve outcome and patient counseling.
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Kühn AL, Chang YM. Traumatic incudomalleolar disarticulation. J Clin Neurosci 2019; 62:242-243. [DOI: 10.1016/j.jocn.2018.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/23/2018] [Indexed: 11/30/2022]
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Kühn AL, Kan P, Srinivasan V, Rex DE, de Macedo Rodrigues K, Howk MC, Wakhloo AK, Puri AS. Flow diverter for endovascular treatment of intracranial mirror segment internal carotid artery aneurysms. Interv Neuroradiol 2018; 25:4-11. [PMID: 30081693 DOI: 10.1177/1591019918792536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To evaluate the feasibility and efficacy of the pipeline embolization device in the treatment of unruptured intracranial mirror segment aneurysms. METHODS Out of a total of 338 subjects, 14 were identified harboring a total of 32 internal carotid artery mirror segment aneurysms that were treated with the pipeline embolization device and were consecutively enrolled into our study. We collected data on patient demographics, modified Rankin scale (mRS) at admission, aneurysm characteristics, clinical outcome at discharge, 3-9 and at 12-18 months as well as angiography results at follow-up. RESULTS Patients' mean age was 52.9 years; baseline mRS was 0 in all subjects. Pipeline embolization device placement was successful in all cases. Post-treatment mRS remained 0 in 13/14 patients. One patient experienced a small intraparenchymal hemorrhage and subarachnoid hemorrhage, associated with a frontoparietal infarction resulting in right upper extremity weakness and aphasia (post-treatment mRS 3). His mRS evaluation remained stable at the 3-9-month follow-up. Three to 9-month follow-up angiography (13/14 subjects) showed complete aneurysm occlusion in 24/30 aneurysms (80%), near complete and partial occlusion in three of 30 (10%) aneurysms each. At the 9-month follow-up, one patient experienced a complete occlusion of the anterior temporal artery branch but did not present with any clinical deficits. No mRS changes were encountered over a median 6-month follow-up period. Mid-term follow-up angiography (12-18 months) available in eight of 14 subjects showed complete aneurysm occlusion in all patients. Mild intimal hyperplasia was observed in one patient. CONCLUSIONS Flow diversion technology can be used for the treatment of unruptured mirror segment aneurysms in selected patients.
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Kühn AL, Dabus G, Kan P, Wakhloo AK, Puri AS. Flow-diverter stents for endovascular management of non-fetal posterior communicating artery aneurysms-analysis on aneurysm occlusion, vessel patency, and patient outcome. Interv Neuroradiol 2018; 24:363-374. [PMID: 29471704 DOI: 10.1177/1591019918759735] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Use of flow-diversion technology in the treatment of incidental and recanalized posterior communicating artery (PComA) aneurysms. Methods Patients treated with the Pipeline embolization device (PED) for PComA aneurysms were identified and included in our retrospective analysis. We evaluated aneurysm characteristics, modified Rankin Scale score (mRS) on admission, angiography follow-up, and patient clinical outcome at discharge, at three to nine months, and at 12-18 months. Results We included 56 patients with a mean age of 56 years. Median mRS on admission was 0. All aneurysms involved the PComA and were either new findings or found to have shown recanalization at angiography follow-up from previous coil embolization or surgical clipping. Intraprocedural device foreshortening was observed in one case requiring additional placement of a self-expanding stent. One intraprocedural aneurysm rupture occurred because of a broken distal wire. This patient had an mRS of 4 after the procedure. Three- to nine-month and 12- to 18-month follow-up angiography showed near complete or complete aneurysm occlusion in most cases. Minimal to mild intimal hyperplasia was seen in five cases at three to nine months. PComA patency over time showed 29 of 46 initially patent vessels still patent at six months. Thirteen and seven PComAs showed progressive decrease in flow at three to nine months and 12-18 months, respectively. Median mRS remained 0 for all patients at three- to nine-month and 12- to 18-month follow-up. Conclusions Our preliminary results show that flow-diversion technology is an effective and safe treatment option. Larger studies with long-term follow-up are needed to validate our promising results.
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Hou SY, Kühn AL, Puri AS, Wakhloo AK. Open-cell stent and use of cone-beam CT enables a safe and effective coil embolization of true ophthalmic artery and anterior choroidal artery aneurysms with preservation of parent vessel: Clinical and angiographic results. Interv Neuroradiol 2017; 24:135-139. [PMID: 29239687 DOI: 10.1177/1591019917747246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Treatment of true ophthalmic artery (OA) or anterior choroidal artery (AChA) aneurysms with preservation of the parent vessel may be challenging. Flow diverters have limitations when dealing with branch vessels arising from the aneurysm sac. Visual loss or AChA territory infarcts have been reported both for surgical and endovascular treatment. Methods We evaluated the safety and efficacy of an open-cell design, laser-cut, self-expanding Nitinol stent, and use of cone-beam computed tomography (CBCT) for stent-assisted coil embolization. Results A total of seven patients with unruptured OA or AChA aneurysms were enrolled in this prospective small case study and the data were analyzed retrospectively. A complete obliteration was achieved in all aneurysms immediately post-intervention or at six-month follow-up without any evidence for recanalization at up to three-year follow-up. All patients tolerated the procedure well and there was no change in baseline modified Rankin Scale. Conclusions Our study suggests that specific features of an open-cell stent allow a safe and effective treatment of OA or AChA aneurysms with a high technical success rate and excellent mid-term angiographic and clinical outcome. CBCT is a useful intraoperative imaging tool.
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Golebiowski D, van der Bom IMJ, Kwon CS, Miller AD, Petrosky K, Bradbury AM, Maitland S, Kühn AL, Bishop N, Curran E, Silva N, GuhaSarkar D, Westmoreland SV, Martin DR, Gounis MJ, Asaad WF, Sena-Esteves M. Direct Intracranial Injection of AAVrh8 Encoding Monkey β-N-Acetylhexosaminidase Causes Neurotoxicity in the Primate Brain. Hum Gene Ther 2017; 28:510-522. [PMID: 28132521 DOI: 10.1089/hum.2016.109] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
GM2 gangliosidoses, including Tay-Sachs disease and Sandhoff disease, are lysosomal storage disorders caused by deficiencies in β-N-acetylhexosaminidase (Hex). Patients are afflicted primarily with progressive central nervous system (CNS) dysfunction. Studies in mice, cats, and sheep have indicated safety and widespread distribution of Hex in the CNS after intracranial vector infusion of AAVrh8 vectors encoding species-specific Hex α- or β-subunits at a 1:1 ratio. Here, a safety study was conducted in cynomolgus macaques (cm), modeling previous animal studies, with bilateral infusion in the thalamus as well as in left lateral ventricle of AAVrh8 vectors encoding cm Hex α- and β-subunits. Three doses (3.2 × 1012 vg [n = 3]; 3.2 × 1011 vg [n = 2]; or 1.1 × 1011 vg [n = 2]) were tested, with controls infused with vehicle (n = 1) or transgene empty AAVrh8 vector at the highest dose (n = 2). Most monkeys receiving AAVrh8-cmHexα/β developed dyskinesias, ataxia, and loss of dexterity, with higher dose animals eventually becoming apathetic. Time to onset of symptoms was dose dependent, with the highest-dose cohort producing symptoms within a month of infusion. One monkey in the lowest-dose cohort was behaviorally asymptomatic but had magnetic resonance imaging abnormalities in the thalami. Histopathology was similar in all monkeys injected with AAVrh8-cmHexα/β, showing severe white and gray matter necrosis along the injection track, reactive vasculature, and the presence of neurons with granular eosinophilic material. Lesions were minimal to absent in both control cohorts. Despite cellular loss, a dramatic increase in Hex activity was measured in the thalamus, and none of the animals presented with antibody titers against Hex. The high overexpression of Hex protein is likely to blame for this negative outcome, and this study demonstrates the variations in safety profiles of AAVrh8-Hexα/β intracranial injection among different species, despite encoding for self-proteins.
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Kühn AL, Wakhloo AK, Gounis MJ, Kan P, de Macedo Rodrigues K, Lozano JD, Marosfoi MG, Perras M, Brooks C, Howk MC, Rex DE, Massari F, Puri AS. Use of self-expanding stents for better intracranial flow diverter wall apposition. Interv Neuroradiol 2016; 23:129-136. [PMID: 27956518 DOI: 10.1177/1591019916681981] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Flow diverter (FD) malapposition is associated with stroke-related complications. We document the use of self-expanding nitinol stents to remove/reduce the ledge of a FD deployed for aneurysm treatment. Methods We identified five patients who were treated with the Pipeline embolization device (PED) in conjunction with a Neuroform EZ stent for inadequate wall apposition of the ends of the FD at our institution between May 2014 and July 2015. Among other parameters, angiographic results, cone-beam computed tomography assessment of wall apposition and patient clinical outcome were evaluated. Results Incomplete device end apposition was seen in three cases, and precarious positioning of the distal end of the PED over the aneurysm neck was seen in two cases. In all five cases, successful treatment with good wall apposition and proper pinning of the PED distal edge was achieved using an additional Neuroform EZ stent. Appropriate aneurysm neck coverage and flow stagnation was seen in all cases. The combination of high radial outward force and open-cell design permits the Neuroform EZ stent to jail the malappositioned edges of the FD while maintaining good vessel-wall apposition itself and prevent migration of the PED. Short-term follow-up angiography showed device patency and complete aneurysm obliteration in all cases. Conclusions Preliminary results of this small case series suggest that the Neuroform EZ stent allows for effective treatment of FD malapposition in selected patients amenable for this endovascular approach. Long-term and larger cohort studies are needed to validate these results.
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Kühn AL, de Macedo Rodrigues K, Lozano JD, Rex DE, Massari F, Tamura T, Howk M, Brooks C, L'Heureux J, Gounis MJ, Wakhloo AK, Puri AS. Use of the Pipeline embolization device for recurrent and residual cerebral aneurysms: a safety and efficacy analysis with short-term follow-up. J Neurointerv Surg 2016; 9:1208-1213. [PMID: 27888225 DOI: 10.1136/neurintsurg-2016-012772] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/30/2016] [Accepted: 11/02/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Evaluation of the safety and efficacy of the Pipeline embolization device (PED) when used as second-line treatment for recurrent or residual, pretreated ruptured and unruptured intracranial aneurysms (IAs). METHODS Retrospective review of our database to include all patients who were treated with a PED for recurrent or residual IAs following surgical clipping or coiling. We evaluated neurological outcome and angiograms at discharge, 6- and 12-months' follow-up and assessed intimal hyperplasia at follow-up. RESULTS Twenty-four patients met our inclusion criteria. Most IAs were located in the anterior circulation (n=21). No change of preprocedure modified Rankin Scale score was seen at discharge or at any scheduled follow-up. Complete or near-complete aneurysm occlusion on 6- and 12-month angiograms was seen in 94.4% (17/18 cases) and 93.3% (14/15 cases), respectively. Complete or near-complete occlusion was seen in 100% of previously ruptured and 85.7% (6/7 cases) and 83.3% (5/6 cases) of previously unruptured cases at the 6- and 12-months' follow-up, respectively. One case of moderate intimal hyperplasia was observed at 6 months and decreased to mild at the 12-months' follow-up. No difference in device performance was observed among pretreated unruptured or ruptured IAs. CONCLUSIONS Treatment of recurrent or residual IAs with a PED after previous coiling or clipping is feasible and safe. There is no difference in device performance between ruptured or unruptured IAs.
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Bertog SC, Grunwald IQ, Kühn AL, Vaskelyte L, Hofmann I, Gafoor S, Reinartz M, Matic P, Sievert H. Acute Stroke Intervention. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Ansari SA, Kühn AL, Honarmand AR, Khan M, Hurley MC, Potts MB, Jahromi BS, Shaibani A, Gounis MJ, Wakhloo AK, Puri AS. Emergent Endovascular Management of Long-Segment and Flow-Limiting Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents. AJNR Am J Neuroradiol 2016; 38:97-104. [PMID: 28059705 DOI: 10.3174/ajnr.a4965] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/18/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although most cervical dissections are managed medically, emergent endovascular treatment may become necessary in the presence of intracranial large-vessel occlusions, flow-limiting and long-segment dissections with impending occlusion, and/or hypoperfusion-related ischemia at risk of infarction. We investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting. MATERIALS AND METHODS We retrospectively studied long-segment carotid dissections requiring stent reconstruction with multiple tandem stents (≥3 stents) and presenting with acute (<12 hours) ischemic stroke symptoms (NIHSS score, ≥4). We analyzed patient demographics, vascular risk factors, clinical presentations, imaging/angiographic findings, technical procedures/complications, and clinical outcomes. RESULTS Fifteen patients (mean age, 51.5 years) with acute ischemic stroke (mean NIHSS score, 15) underwent endovascular stent reconstruction for vessel and/or ischemic tissue salvage. All carotid dissections presented with >70% flow limiting stenosis and involved the distal cervical ICA with a minimum length of 3.5 cm. Carotid stent reconstruction was successful in all patients with no residual stenosis or flow limitation. Nine patients (60%) harbored intracranial occlusions, and 6 patients (40%) required intra-arterial thrombolysis/thrombectomy, achieving 100% TICI 2b-3 reperfusion. Two procedural complications were limited to thromboembolic infarcts from in-stent thrombus and asymptomatic hemorrhagic infarct transformation (7% morbidity, 0% mortality). Angiographic and ultrasound follow-up confirmed normal carotid caliber and stent patency, with 2 cases of <20% in-stent stenosis. Early clinical improvement resulted in a mean discharge NIHSS score of 6, and 9/15 (60%) patients achieved a 90-day mRS of ≤2. CONCLUSIONS Emergent stent reconstruction of long-segment and flow-limiting carotid dissections in acute ischemic stroke intervention is safe and effective, with favorable clinical outcomes, allowing successful thrombectomy, vessel salvage, restoration of cerebral perfusion, and/or prevention of recurrent thromboembolic stroke.
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Kühn AL, Grunwald IQ. [A hitchhiker's guide to the neuron galaxy : On the trail of the secrets of the brain with resting-state fMRI]. Radiologe 2016; 56:957-958. [PMID: 27695878 DOI: 10.1007/s00117-016-0173-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kühn AL, Wakhloo AK, Lozano JD, Massari F, De Macedo Rodrigues K, Marosfoi MG, Perras M, Brooks C, Howk M, Rex DE, Gounis MJ, Puri AS. Two-year single-center experience with the ‘Baby Trevo’ stent retriever for mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg 2016; 9:541-546. [DOI: 10.1136/neurintsurg-2016-012454] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/13/2016] [Accepted: 05/17/2016] [Indexed: 11/03/2022]
Abstract
ObjectiveTo evaluate the safety and efficacy of the ‘Baby Trevo’ (Trevo XP ProVue 3×20 mm Retriever) stent retriever for large vessel occlusions (LVOs) in acute ischemic stroke (AIS).Materials and methodsWe retrospectively analyzed our stroke database and included all patients treated with the Baby Trevo for distal LVOs in AIS. Patient gender, mean age, vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score at presentation, and modified Rankin Scale (mRS) score at baseline and 90-day follow-up were documented. Reperfusion rates for the vessels treated were recorded using the Thrombolysis in Cerebral Infarction (TICI) classification. Occurrence of vasospasm and new or evolving infarcts in the treated vascular territory was documented.ResultsThirty-five subjects with a mean NIHSS score of 18 were included. The Baby Trevo device was used in 38 branches of the anterior and posterior circulations. TICI 2b/3 blood flow was restored after one single pass in 20/38 (52.6%) and after two or three passes in 11 vessels. The remaining vessels required either more than three passes, showed less than a TICI 2b/3 reperfusion (n=3), or demonstrated failure to retrieve the clot (n=4). TICI 2b/3 reperfusion was achieved in 30 patients (85.7%). No vessel injuries, rupture, or significant vasospasm were seen. Overall, a mRS score of ≤2 was seen in 56.5% of the subjects successfully treated with the Baby Trevo at 90 days and in 81.3% of surviving patients; seven patients died (20%).ConclusionsOur preliminary data suggest that the ‘Baby Trevo’ achieves a high recanalization rate without any significant risk. Larger cohort studies are needed to validate the clinical benefit.
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Lozano JD, Massari F, Howk MC, de Macedo Rodrigues K, Brooks C, Perras M, Rex DE, Wakhloo AK, Kühn AL, Puri AS. Utilization of a New Intracranial Support Catheter as an Intermediate Aspiration Catheter in the Treatment of Acute Ischemic Stroke: Technical Report on Initial Experience. Cureus 2016; 8:e617. [PMID: 27382525 PMCID: PMC4917373 DOI: 10.7759/cureus.617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The endovascular management of acute ischemic stroke (AIS) due to emergency large vessel occlusion (ELVO) has become the standard of care after the recent publication of landmark randomized, controlled trials. Mechanical thrombectomy, in addition to intravenous thrombolysis (within 4.5 hours when eligible), is now part of the algorithm of the standard of care when treating AIS in patients with ELVO in the anterior circulation up to six hours after symptom onset. A newly introduced device, the Arc™ intracranial support catheter (Medtronic, Irvine, USA), is specifically designed for the introduction of neurointerventional devices into the cerebral vasculature and facilitates the delivery of microcatheters into smaller, more distal intracranial vessels. This technical report describes the use of the Arc™ intracranial support catheter in the setting of AIS.
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Kühn AL, Kan P, Massari F, Lozano JD, Hou SY, Howk M, Gounis MJ, Wakhloo AK, Puri AS. Endovascular reconstruction of unruptured intradural vertebral artery dissecting aneurysms with the Pipeline embolization device. J Neurointerv Surg 2015; 8:1048-51. [DOI: 10.1136/neurintsurg-2015-012028] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/16/2015] [Indexed: 11/04/2022]
Abstract
BackgroundDissecting aneurysms of the vertebral artery (VA) are difficult to treat using current surgical and endovascular techniques.ObjectiveTo analyze retrospectively the efficacy and safety of flow diverters in the treatment of dissecting aneurysms of the vertebral artery.MethodsWe identified six patients with six unruptured VA dissecting aneurysms either arising from the V4 or V3–V4 junction that were treated with the Pipeline embolization device (PED) at our institution between July 2012 and February 2015. Among other parameters, technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated.ResultsPED placement was achieved in all cases and immediate angiography follow-up demonstrated intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of dysarthria was noted in one patient. Major procedure-related complications were not observed. The 6-month follow-up (n=6) demonstrated complete/near-complete aneurysm obliteration in five patients and partial obliteration in one. At the 1-year follow-up (n=5) stable complete aneurysm occlusion was seen in two patients. Two cases showed progression from near complete occlusion and partial occlusion at 6 months to complete occlusion and near complete occlusion. One cases showed unchanged near complete occlusion. No aneurysmal bleeding, in-stent stenosis or thromboembolic complication was seen. National Institutes of Health Stroke Scale and modified Rankin scale scores remained unchanged from admission to discharge.ConclusionsOur preliminary experience with the use of PED for the treatment of intradural VA dissecting aneurysms shows promising short-term results, making this technique a feasible and safe treatment option in patients suitable for this approach. However, long-term and larger cohort studies are needed to validate these results.
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Kühn AL, Hou SY, Puri AS, Silva CF, Gounis MJ, Wakhloo AK. Stent-assisted coil embolization of aneurysms with small parent vessels: safety and efficacy analysis. J Neurointerv Surg 2015; 8:581-5. [PMID: 26041097 DOI: 10.1136/neurintsurg-2015-011774] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/11/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Stent-assisted coil embolization (SACE) is a viable therapeutic approach for wide-neck intracranial aneurysms. However, it can be technically challenging in small cerebral vessels (≤2 mm). OBJECTIVE To present our experience with stents approved for SACE in aneurysms with small parent arteries. METHODS All patients who underwent stent-assisted aneurysm treatment with either a Neuroform or an Enterprise stent device at our institution between June 2006 and October 2012 were identified. Additionally, we evaluated each patient's vascular risk factors, aneurysm characteristics (ruptured vs non-ruptured, incidental finding, recanalized) and follow-up angiography data. RESULTS A total of 41 patients with 44 aneurysms met our criteria, including 31 women and 10 men. Most of the aneurysms were located in the anterior circulation (75%). Stent placement in vessels 1.2-2 mm in diameter was successful in 93.2%. Thromboembolic complications occurred in 6 cases and vessel straightening was seen in 1 case only. Initial nearly complete to complete aneurysm obliteration was achieved in 88.6%. Six-month follow-up angiography showed coil compaction in three cases, one asymptomatic in-stent stenosis and stent occlusion. Twelve to 20-months' follow-up showed stable coil compaction in two patients compared with previous follow-up, and aneurysm recanalization in two patients. Twenty-four to 36-months' follow-up showed further coil compaction in one of these patients and aneurysm recanalization in a previous case of stable coil compaction on mid-term follow-up. CONCLUSIONS Our results suggest that SACE of aneurysms with small parent vessels is feasible in selected cases and shows good long-term patency rates of parent arteries.
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Grunwald IQ, Reith W, Kühn AL, Balami JS, Karp K, Fassbender K, Walter S, Papanagiotou P, Krick C. Proximal protection with the Gore PAES can reduce DWI lesion size in high-grade stenosis during carotid stenting. EUROINTERVENTION 2015; 10:271-6. [PMID: 24531258 DOI: 10.4244/eijv10i2a45] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim was to determine the incidence of new ischaemic lesions on diffusion-weighted MR imaging (DWI) in a non-randomised cohort of patients after protected and unprotected carotid artery stent placement using the Parodi Anti-Emboli System (PAES). METHODS AND RESULTS A retrospective review was conducted on 269 patients who received DWI prior to, and 24-72 hours after, stent placement. All patients were enrolled in one centre. Forty patients stented with the PAES device were matched with 229 patients stented without protection (control group). New diffusion restriction on DWI was detected in 25.8% (PAES) versus 32.3% (control group); p=0.64. On average there were 0.7 lesions (PAES) versus 0.8 lesions (control group) per patient. The area of lesions was 1.7 (PAES) versus 5.6 mm2. In a subanalysis of patients (32 PAES, 148 non-protected) with >80% stenosis, the area of restricted diffusion was less when proximal protection was used (p<0.05). The number and area of DWI lesions did not differ on the contralateral, non-stented side. When the PAES system was used, patients were more likely not to have any lesion at all (p=0.028). CONCLUSIONS In high-grade stenosis, the use of the Gore PAES device significantly reduced the area of new DWI lesions and patients were more likely not to have any new DWI lesion at all.
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Golebiowski D, Bradbury AM, Kwon CS, van der Bom IMJ, Stoica L, Johnson AK, Wilson DU, Gray-Edwards HL, Hudson JA, Johnson JA, Randle AN, Whitlock BK, Sartin JL, Kühn AL, Gounis M, Asaad W, Martin DR, Sena-Esteves M. AAV Gene Therapy Strategies for Lysosomal Storage Disorders with Central Nervous System Involvement. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/978-1-4939-2306-9_11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Gounis MJ, van der Bom IMJ, Wakhloo AK, Zheng S, Chueh JY, Kühn AL, Bogdanov AA. MR imaging of myeloperoxidase activity in a model of the inflamed aneurysm wall. AJNR Am J Neuroradiol 2015; 36:146-52. [PMID: 25273534 DOI: 10.3174/ajnr.a4135] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although myeloperoxidase activity in vivo can be visualized by using noninvasive imaging, successful clinical translation requires further optimization of the imaging approach. We report a motion-sensitized driven-equilibrium MR imaging approach for the detection of a myeloperoxidase activity-specific gadolinium-containing imaging agent in experimental aneurysm models, which compensates for irregular blood flow, enabling vascular wall imaging in the aneurysm. MATERIALS AND METHODS A phantom was built from rotational angiography of a rabbit elastase aneurysm model and was connected to a cardiac pulse duplicator mimicking rabbit-specific flow conditions. A T1-weighted turbo spin-echo-based motion-sensitized driven-equilibrium pulse sequence was optimized in vitro, including the addition of fat suppression and the selection of the velocity-encoding gradient parameter. The optimized sequence was applied in vivo to rabbit aneurysm models with and without inflammation in the aneurysmal wall. Under each condition, the aneurysms were imaged before and after intravenous administration of the imaging agent. The signal-to-noise ratio of each MR imaging section through the aneurysm was calculated. RESULTS The motion-sensitized driven-equilibrium sequence was optimized to reduce flow signal, enabling detection of the myeloperoxidase imaging agent in the phantom. The optimized imaging protocol in the rabbit model of saccular aneurysms revealed a significant increase in the change of SNR from pre- to post-contrast MR imaging in the inflamed aneurysms compared with naïve aneurysms and the adjacent carotid artery (P < .0001). CONCLUSIONS A diagnostic MR imaging protocol was optimized for molecular imaging of a myeloperoxidase-specific molecular imaging agent in an animal model of inflamed brain aneurysms.
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Kühn AL, Grunwald IQ. [O tempora, o mores - unlocking a new area in healthcare training]. Radiologe 2014; 55:6. [PMID: 25519899 DOI: 10.1007/s00117-014-2790-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kühn AL, Hou SY, Perras M, Brooks C, Gounis MJ, Wakhloo AK, Puri AS. Flow diverter stents for unruptured saccular anterior circulation perforating artery aneurysms: safety, efficacy, and short-term follow-up. J Neurointerv Surg 2014; 7:634-40. [PMID: 25051964 DOI: 10.1136/neurintsurg-2014-011237] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/29/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND Anterior circulation perforating artery aneurysms including anterior choroidal artery and lenticulostriate artery aneurysms are rare. Injury to these vessels can lead to severe debilitating symptoms. OBJECTIVE To present a new approach to treatment using flow diversion technology. METHODS Patients treated with a Pipeline embolization device (PED) for perforator artery aneurysms at our institution between June 2012 and May 2013 were identified and included in our retrospective analysis. We evaluated patient vascular risk factors; family history of aneurysms; aneurysm characteristics; National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) on admission; and angiography follow-up and patient clinical outcome at discharge, 6 months, and 1 year. RESULTS We included four patients with a mean age of 59.8 years. Two patients had a positive family history of aneurysms. Patient vascular risk factors included smoking, dyslipidemia, and hypertension. All patients presented with a NIHSS and mRS of 0 on admission. Aneurysms were located at the anterior choroidal (n=2) or lenticulostriate artery (n=2) and were treated with a single PED. No periprocedural or postprocedural complications occurred. The patients were discharged with no change in NHISS or mRS score. Six-month and 1-year follow-up angiography showed complete aneurysm occlusion. Mild intimal hyperplasia was seen in 2 cases at 6 months, but was resolved at the 1-year follow-up. No re-treatment was necessary. NIHSS and mRS remained 0 at follow-up time points. CONCLUSIONS Our preliminary results show that flow diversion technology is an effective and safe therapy for complex, hard-to-treat aneurysms in perforating arteries. Larger studies with long-term follow-up are needed to validate our promising results.
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Kühn AL, Hou SY, Spilberg G, Wakhloo AK. Visualization of a small hidden intracranial aneurysm during endovascular thrombectomy for acute MCA occlusion. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2014; 7:47-49. [PMID: 24920989 PMCID: PMC4051905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Spontaneous aneurysmal thrombosis as a cause for acute ischemic stroke is a rarely described complication of small unruptured intracranial aneurysms. We present an interesting case of a stroke in a woman with an occult acutely thrombosed middle cerebral artery bifurcation aneurysm that was found during successful thrombus aspiration of the occluded parent vessel. Although rare, small aneurysms have to be considered as a possible cause for a thrombotic vessel occlusion. Catheters and thrombectomy devices have to be used carefully while performing mechanical revascularization.
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