Stroke Review

Stent-Grafts in the Management of Hemorrhagic Complications Related to Hemostatic Closure Devices: Report of Two Cases

We report 2 cases of hemorrhagic complications related to use of the Angio-Seal hemostatic closure device that were successfully managed with stent-grafts. Two patients with subarachnoid hemorrhage were referred to our departments for endovascular treatment of ruptured intracranial aneurysms. The treatment was performed through a femoral access; the sheaths were removed immediately after the procedures, and the punctures sites closed by Angio-Seals. Both patients presented clinical signs of hypovolemic shock after treatment. The diagnosis of active bleeding through the puncture site was made by emergency digital subtraction angiography. The lesions were managed with stent-grafts. The use of stent-grafts proved to be efficient in the management of these life-threatening hemorrhagic complications following the use of the Angio-Seal hemostatic closure device.

Elective treatment of saccular and broad-necked intracranial aneurysms using a closed-cell nitinol stent (Leo)

OBJECTIVE

Endovascular coil embolization of saccular intracranial aneurysms is safe and effective, but long-term results are dissatisfying. Reconstructive treatments using stents improve occlusion rate and protect parent vessels. We present data on our experience with a new self-expanding stent manufactured with braided nitinol wires.

METHODS

Twenty-five saccular, complex, and broad-necked intracranial aneurysms in 21 patients were treated electively. They were located at the internal carotid artery (10), basilar trunk (5), cavernous carotid artery (4), basilar tip (2), anterior cerebral artery (2), anterior communicating artery (1), and middle cerebral artery (1). Eleven aneurysms exhibited recanalization after primary endovascular treatment without stent.

RESULTS

Stent deployment was successful in 24 lesions, and additional coil embolization was performed in 23. No permanent neurological deficits were encountered consequent to endovascular procedure. Complete or partial occlusion immediately after stent deployment was achieved in 19 aneurysms, whereas no immediate coil embolization was chosen in 6 cases. There were two thromboembolic events related to the deployment of the Leo stent, one failure of stent deployment, difficulties in stent positioning in three cases, and one asymptomatic parent artery occlusion after 7 months. Follow-up (available in 18 patients and 21 aneurysms and obtained at 3-12 mo; average, 5 mo) revealed patent stents in the remaining cases. Angiographic recurrences arose in three lesions, which were retreated without complications.

CONCLUSION

Primary and recurrence treatment of saccular and broad-necked intracranial aneurysms using the Leo stent is feasible and effective. No permanent neurological deficits were associated with stent placement. Short-term follow-up identified intact parent arteries and stable occlusion rates in the majority of cases.

Anesthesia for neuroradiology

PURPOSE OF REVIEW

The role of anesthesia outside the operating room is rapidly expanding and evolving alongside with the advances in interventional neuroradiology. Increasingly complex diagnostic and therapeutic neuroradiological procedures are being performed on sicker patients. This review provides an overview of the principles of anesthetic management and summarizes recent advances in interventional neuroradiology.

RECENT FINDINGS

There are many new areas of development in interventional neuroradiology, but each also brings with it controversy. Use of newer agents for anesthesia and for anticoagulation may change the intraoperative management of patients. The role of neurophysiological monitoring during endovascular procedures is still to be validated. The optimal mode of treating cerebral aneurysms is still being debated. There has been increasing interest in and evidence of the efficacy of carotid artery stenting in the treatment of carotid artery disease. The utility of intraoperative magnetic resonance imaging in neurosurgery is expanding rapidly.

SUMMARY

Providing anesthesia in the interventional neuroradiology suite continues to be a challenge to the anesthesiologist. Understanding the anesthetic constraints and complexities and keeping abreast of the current developments in neuroradiology are crucial in ensuring the maximal benefits to and safety of patients.