Endovascular treatment of 346 middle cerebral artery aneurysms: results of a 16-year single-center experience

BACKGROUND

The endovascular treatment of middle cerebral artery (MCA) aneurysms has been controversial because of the frequency of complex anatomy and the relative ease of surgical clipping in this location.

OBJECTIVE

To present a large single-center experience with the endovascular treatment of MCA aneurysms.

METHODS

The neurointerventional database at our institution was reviewed for all endovascular treatments of MCA aneurysms. Demographics, aneurysm characteristics, treatment modality, intraprocedural hemorrhagic and thromboembolic events, 30-day neurological events, and follow-up angiographic studies were recorded.

RESULTS

From December 1996 to April 2013, 292 patients underwent endovascular treatment of 346 MCA aneurysms. Of these, 341 (98.6%) were successfully completed. Balloon neck remodeling was used in 230 procedures (66.5%). Ninety-five procedures (27.4%) were for ruptured aneurysms. The rate of intraprocedural hemorrhage was 2.6% (9 of 346). The overall rate of intraprocedural thromboembolic events was 13.6% (47 of 346), significantly more common in patients with acute subarachnoid hemorrhage (27.4%; P < .001). The 30-day major (modified Rankin Scale score > 2) neurological event rate was 2.9% (10 of 346), significantly more common in patients with subarachnoid hemorrhage (8.4%) compared with those without (0.8%; P < .001). The rate of complete or near-complete aneurysm occlusion at was 90.6% ≥ 6 months and 91.8% at ≥ 2 years, with an average of 24 months of follow-up available for 247 procedures.

CONCLUSION

Endovascular treatment of MCA aneurysms can be safe and effective. However, it is associated with a high asymptomatic thromboembolic event rate that is more frequent in the setting of acute subarachnoid hemorrhage.

Postpartum reversible cerebral vasoconstriction syndrome: Review and analysis of the current data

Postpartum reversible cerebral vasoconstriction syndrome (PPRCVS) is a rare but serious cause of headache that occurs in the early postpartum period. The rarity of this disorder has limited the current literature to single case reports and small, observational case series. The lack of familiarity with PPRCVS may contribute to mismanagement of these unique patients and lead to poor outcomes. To address current gaps in the understanding of PPRCVS, this review and data analysis characterizes the demographics, presentation, clinical course, management and prognosis of PPRCVS and provides a general review of the epidemiology, pathophysiology and diagnosis to assist clinicians who may care for patients with this rare disorder.

Incidence and mechanisms of stroke after permanent carotid artery occlusion following temporary occlusion testing

BACKGROUND AND PURPOSE

Patients who require sacrifice of the internal carotid artery (ICA) have a substantial risk of stroke, despite preoperative testing with temporary balloon occlusion (TBO). The purpose of this study is to examine the incidence and mechanisms of stroke after permanent carotid artery occlusion in this population.

METHODS

Consecutive patients undergoing TBO testing from March 2002 to December 2011 were identified. The protocol included 30 min of balloon occlusion, continuous intraprocedural neurological assessment, angiographic imaging of collateral flow during the occlusion, and perfusion imaging. Clinical records were reviewed for procedure results, procedural complications, and the incidence and causes of stroke, transient ischemic attack (TIA) and death over 6 months. Strokes were categorized as thromboembolic or hypoperfusion based on available clinical and imaging data.

RESULTS

One hundred and fifty carotid occlusion tests were performed during the study period, including 84 women and 66 men. No procedural strokes were recorded. Thirty-seven patients (25%) had permanent occlusion of the tested ICA. Six of the 37 patients had ipsilateral stroke (16.2%) and three experienced TIA (8.1%). Two strokes occurred in the immediate postoperative period (thromboembolic), two strokes occurred within days of ICA occlusion (hypoperfusion), and two strokes occurred at least 30 days from the time of ICA occlusion (thromboembolic).

CONCLUSIONS

The rate of ischemic stroke following carotid sacrifice remains high and most strokes are thromboembolic in nature. Our testing protocol did not eliminate the risk of hypoperfusion-related stroke. Delayed venous phase by angiography may be a better indicator of hemodynamic tolerance than perfusion imaging.

Direct puncture sclerotherapy of a thoracic duct cyst presenting as an enlarging left supraclavicular mass

A 58-year-old woman presented with a palpable mass at the base of the left neck which she had first noticed 12 years previously, shortly after abdominal surgery. The mass had progressively enlarged, resulting in dysphagia, dyspnea and occasional pain. Imaging showed a septated but otherwise simple cystic mass extending into the mediastinum and containing lymphocytic fluid on aspiration. A diagnosis of the rare entity of a thoracic duct cyst with supraclavicular extension was made. The patient opted for percutaneous sclerotherapy of the lesion, which was performed using glacial acetic acid. This resulted in complete resolution of the mass with one treatment. After exclusion of other causes of cystic left supraclavicular masses including cystic neoplasms and pseudoaneurysms of the carotid or subclavian arteries, direct puncture sclerotherapy can be safe and effective.

Last-recorded P2Y12 reaction units value is strongly associated with thromboembolic and hemorrhagic complications occurring up to 6 months after treatment in patients with cerebral aneurysms treated with the pipeline embolization device

BACKGROUND AND PURPOSE

A recent study identified a preprocedural P2Y12 reaction units value of <60 or >240 as a strong independent predictor of perioperative thromboembolic and hemorrhagic complications after treatment of cerebral aneurysms with the Pipeline Embolization Device. This study aimed to determine whether a last-recorded P2Y12 reaction units value of <60 or >240 predicts thromboembolic and hemorrhagic complications up to 6 months after treatment of cerebral aneurysms with the Pipeline Embolization Device in the same patient cohort.

MATERIALS AND METHODS

We recorded patient and aneurysm characteristics, P2Y12 receptor antagonist administered, P2Y12 reaction units value with VerifyNow, procedural variables, and thromboembolic and hemorrhagic complications up to 6 months after Pipeline Embolization Device procedures at our institution during an 8-month period. Complications causing a permanent disabling neurologic deficit or death were considered major. Multivariate regression analysis was performed to identify independent predictors of thromboembolic and hemorrhagic complications.

RESULTS

Forty-four patients underwent 48 Pipeline Embolization Device procedures at our institution during the study period. There were 11 thromboembolic and hemorrhagic complications up to 6 months after treatment in our cohort (22.9%), 5 of which were major (10.4%). A last-recorded P2Y12 reaction units value of <60 or >240 was the only independent predictor of all (P = .002) and major (P = .03) thromboembolic and hemorrhagic complications in our cohort. Most patients (71%) required, on average, 2 adjustments to the dose or type of P2Y12 receptor antagonist to remain within the 60-240 target P2Y12 reaction units range.

CONCLUSIONS

In our cohort, a last-recorded P2Y12 reaction units value of <60 or >240 was the only independent predictor of all and major thromboembolic and hemorrhagic complications up to 6 months after Pipeline Embolization Device procedures.

Differences in the Basilar Artery Bifurcation Angle Among Patients Who Present With a Ruptured Aneurysm at the Top of the Basilar Artery and Patients With Perimesencephalic Subarachnoid Hemorrhage

BACKGROUND:

The angle of the basilar artery bifurcation of (BAB angle) is thought to influence the risk of the development and rupture of aneurysms at this site. It is, however, unknown whether the BAB angle also influences the incidence of angiographically negative perimesencephalic subarachnoid hemorrhage (PMSAH).

OBJECTIVE:

We performed a retrospective cross-sectional study comparing the BAB angle in a series of patients who presented with subarachnoid hemorrhage from a ruptured aneurysm at the top of the basilar artery (BSAH) with the BAB angle in a series of patients who presented with PMSAH.

METHODS:

Consecutive patients who presented to our institution with PMSAH or BSAH between January 1, 2005 and December 31, 2010 were studied. Patients with PMSAH were further subdivided into patients with classic PMSAH (CPMSAH) and those with nonclassic PMSAH (NCPMSAH) based on initial head computed tomography examinations. In each patient, the BAB angle was measured on the standard cranial anteroposterior projections after vertebral artery injections.

RESULTS:

A total of 21 patients with CPMSAH, 30 patients with NCPMSAH, and 31 patients with BSAH were studied. The BAB angle was significantly smaller in patients with CPMSAH (87.7 ± 17.1 degrees) and NCPMSAH (98.4 ± 21.1 degrees) compared with patients with BSAH (135.0 ± 30.8 degrees) (P &lt; .001).

CONCLUSION:

The significantly lower BAB angle in PMSAH patients compared with BSAH patients suggests that bleeding in PMSAH is either nonarterial in nature or is secondary to variations in hemodynamic arterial stress at the top of the basilar artery that need to be studied further with computational models.

Size and anatomic location of ruptured intracranial aneurysms in patients with single and multiple aneurysms: a retrospective study from a single center

BACKGROUND AND PURPOSE

The difference in the relationship between the size of intracranial aneurysms (IAs) and their risk of rupture in patients with singe IAs versus those with multiple IAs is unclear. We sought to retrospectively analyze the size of ruptured IAs (RIAs) in patients with single and multiple IAs in order to study this relationship further.

METHODS

We retrospectively measured the size and location of RIAs in all patients who presented to our institute with an acute subarachnoid hemorrhage between 1 January 2005 and 31 December 2010. The IAs were classified by size into very small IAs or VSAs (≤3 mm), small IAs or SAs (>3 mm but ≤7 mm) and others (>7 mm).

RESULTS

379 patients (281 with a single IA, Group 1 and 98 with multiple IAs, Group 2) with 419 treated RIAs were included in the study. VSAs and SAs constituted the majority of RIAs in both groups (33.5% and 45.2% in Group 1 and 24.6% and 50.7% in Group 2) and the mean size of the RIAs was not different between the two groups. VSAs constituted almost two-thirds of all RIAs in certain locations whereas IAs > 7 mm in size did not constitute more than a third of the RIAs at any of the arterial locations.

CONCLUSIONS

The high incidence of VSAs, particularly in certain locations in both patient subgroups, suggests that current diagnostic, prognostic and therapeutic options in the management of IAs should be more tailored towards the management of these difficult-to-treat lesions.

Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy

Dilating HIV vasculopathy can be a cause of ischemic and hemorrhagic stroke in patients with HIV. Although first identified in children, this condition is increasingly being recognized in adults and has a dismal natural history under medical or expectant management. Vessel wall invasion by varicella zoster virus, HIV or Mycobacterium avium intracellulare complex (MAI) has been postulated as a possible etiology. We present a case of an adult patient with HIV and chronic disseminated MAI infection who presented with ischemic stroke and three fusiform cerebral aneurysms that were successfully treated with the pipeline embolization device (PED). Flow diversion may be a viable treatment option for patients presenting with this serious neurovascular condition when aneurysm location precludes parent vessel sacrifice or surgical bypass. In addition, platelet function testing with VerifyNow may be valuable in selecting the appropriate P2Y12 receptor antagonist to be used in order to prevent PED thrombosis, since some of the antiretroviral drugs may inhibit clopidogrel or prasugrel metabolism.

Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy

Dilating HIV vasculopathy can be a cause of ischemic and hemorrhagic stroke in patients with HIV. Although first identified in children, this condition is increasingly being recognized in adults and has a dismal natural history under medical or expectant management. Vessel wall invasion by varicella zoster virus, HIV or Mycobacterium avium intracellulare complex (MAI) has been postulated as a possible etiology. We present a case of an adult patient with HIV and chronic disseminated MAI infection who presented with ischemic stroke and three fusiform cerebral aneurysms that were successfully treated with the pipeline embolization device (PED). Flow diversion may be a viable treatment option for patients presenting with this serious neurovascular condition when aneurysm location precludes parent vessel sacrifice or surgical bypass. In addition, platelet function testing with VerifyNow may be valuable in selecting the appropriate P2Y12 receptor antagonist to be used in order to prevent PED thrombosis, since some of the antiretroviral drugs may inhibit clopidogrel or prasugrel metabolism.

Abstract WMP25: Single-Center Experience with Dual Antiplatelet Therapy Management in Patients Treated with the Pipeline Embolization Device

Purpose: To determine the number of clopidogrel or prasugrel dose adjustments needed and final DAT regimen used to maintain patients undergoing Pipeline Embolization Device (PED) procedures within a target P2Y12 inhibition range.

Methods: We recorded the number of clopidogrel or prasugrel dose adjustments, final DAT regimen and thromboembolic and hemorrhagic complications in patients undergoing PED procedures at our institution over an 8-month period. P2Y12 inhibition was measured with VerifyNow 10 and 30 days after dose adjustments (target range 80-200 P2Y12 reaction units). Patients received 325mg aspirin daily.

Results: Forty-four patients underwent PED procedures at our institution during the study period, 36 female and 8 male, mean age 59 years (median 63 years, range 31-81 years). Thirteen patients did not require dose adjustments to remain within the target P2Y12 inhibition range (30%). Thirty-one patients required dose adjustments to remain within the target P2Y12 inhibition range (70%), with a mean of 2.1 dose adjustments per patient (median 2, range 1-5), and a mean time from initiation of DAT to last dose adjustment of 47.5 days (median 42 days, range 8-149 days). Four patients exceeded the target P2Y12 inhibition range after a dose adjustment (13%, 3 prasugrel, 1 clopidogrel), without complications. The table summarizes the final DAT regimen and associated major thromboembolic and hemorrhagic complications leading to death or a permanent neurological deficit in our cohort. Most major complications (80%) occurred in patients who were outside the target P2Y12 inhibition range shortly before or at the time of the complication.

Conclusion: The majority of patients undergoing PED procedures in our cohort (70%) required an average of 2 clopidogrel or prasugrel dose adjustments to remain within a target P2Y12 inhibition range. Future research is needed to determine if active management of DAT may decrease the risk of major complications after PED procedures.

Abstract TP84: Delayed Ipsilateral Intraparenchymal Hemorrhage After Neuroform Stent Assisted Coiling of Intracranial Aneurysms

Background: Delayed ipsilateral intraparenchymal hemorrhage (IPH) has been reported following technically successful treatment of intracranial aneurysms using flow-diverting stents (Pipeline embolization device) in 8.5% of patients and does not appear to be related entirely to dual antiplatelet therapy. We report a similar phenomenon in Neuroform-assisted coiling.

Methods: Neuroform-assisted coiling patients were entered into a prospective registry at our institution. Procedural and 30 day complications were recorded. Delayed ipsilateral IPH cases within 30 days were reviewed.

Results: Between 11/2002 and 7/2012, 98 patients had Neuroform-assisted coiling of 100 cerebral aneurysms, 8 acutely ruptured. Intra-procedurally, there were 3 thromboembolic events and 4 hemorrhages due to vessel or aneurysm perforation (not necessarily symptomatic). After the procedure but within 30 days follow-up (available for 92 patients), there were 6 TIA’s, 2 minor strokes and 1 SAH. There were 2 cases of ipsilateral IPH (2%). One was a 60-year-old man who had stent-assisted coiling of an ACOM aneurysm (Neuroform from right A1 into left A2). He was on aspirin 81 mg and clopidogrel 75 mg daily with a PRU (P2Y12 reaction units) of 72 on day of procedure. Despite decreasing clopidogrel dosing to every other day, he had a frontal lobe IPH 7 days later (Figure 1) with a PRU of 59. The other IPH (Figure 2) occurred in a 70-year-old man 14 days after Y-stent assisted coiling of an MCA aneurysm. He was on clopidogrel 75 mg and warfarin (INR 2.0) for prior pulmonary embolism and dural venous sinus thrombosis. Both patients recovered without neurological deficit.

Conclusion: Recently described in flow diversion, delayed ipsilateral IPH is not limited to flow-diverting stents. Though less frequent, a potential for this may exist following any intracranial stenting procedure, possibly related to hemorrhagic conversion of microembolic phenomenon while on dual antiplatelets or anticoagulation.

Abstract TP76: Medium-Term Angiographic Follow-up and Packing Density Analysis in a Series of 67 Consecutive Intracranial Aneurysms Treated Endovascularly with a Single Coil

Purpose: To determine the medium-term angiographic outcome and packing density threshold for complete aneurysm occlusion at follow-up in a series of cerebral aneurysms treated with a single coil.

Methods: We retrospectively identified all cerebral aneurysms treated with a single coil at our institution from July 1997 until September 2011. We recorded aneurysm dimensions, neck size, packing density, and follow-up catheter or MR angiograms to determine the angiographic outcome at last follow-up according to the Raymond scale. We then performed receiver operating characteristic (ROC) analysis of the likelihood of complete aneurysm occlusion at follow-up to determine the packing density maximum operating point (MOP).

Results: Eighty-one aneurysms in 79 patients were treated with a single coil at our institution during the study period. Sixty-four patients were female (81%) and mean age was 53 years (range 23-87 years). Mean maximum aneurysm dimension was 2.8mm (range 1.6-4.8mm), and mean dome-to-neck ratio was 1.3 (median 1.3, range 0.8-1.9). Mean aneurysm packing density was 35.3% (median 32.8%, range 10.2-94.3%). Three patients with ruptured aneurysms died during the hospitalization (7.7%), and follow-up angiographic examinations were performed in 65 patients with 67 aneurysms (85.9%). Mean time to last angiographic follow-up was 26.4 months (range 4-102 months). Complete aneurysm occlusion at last follow-up was present in 46 aneurysms (68.7%), a neck remnant in 16 aneurysms (23.9%) and sac recanalization in 5 aneurysms (7.4%). ROC analysis of the likelihood of complete aneurysm occlusion at last follow-up yielded a packing density MOP of >36.3%, with a specificity of 85.7%, sensitivity of 47.8%, and an area under the curve of 0.61 (95%CI 0.49-0.73). There was a statistically-significant difference in the likelihood of complete aneurysm occlusion at last follow-up between the 25 aneurysms with a packing density >36.3% (88%), and the 42 aneurysms with a packing density ≤36.3% (57.1%, OR 5.5 [95%CI 1.4-21.3], p-value 0.009).

Conclusion: Achieving a packing density >36.3% predicts a significantly higher likelihood (88%) of complete aneurysm occlusion at medium-term angiographic follow-up in cerebral aneurysms treated with a single coil.

Symptomatic patients with intraluminal carotid artery thrombus: outcome with a strategy of initial anticoagulation

OBJECT

The aim of this study was to define the optimal treatment for patients with symptomatic intraluminal carotid artery thrombus (ICAT).

METHODS

The authors performed a retrospective chart review of patients who had presented with symptomatic ICAT at their institution between 2001 and 2011.

RESULTS

Twenty-four patients (16 males and 8 females) with ICAT presented with ischemic stroke (18 patients) or transient ischemic attack ([TIA], 6 patients). All were initially treated using anticoagulation with or without antiplatelet drugs. Eight of these patients had no or only mild carotid artery stenosis on initial angiography and were treated with medical management alone. The remaining 16 patients had moderate or severe carotid stenosis on initial angiography; of these, 10 underwent delayed revascularization (8 patients, carotid endarterectomy [CEA]; 2 patients, angioplasty and stenting), 2 refused revascularization, and 4 were treated with medical therapy alone. One patient had multiple TIAs despite medical therapy and eventually underwent CEA; the remaining 23 patients had no TIAs after treatment. No patient suffered ischemic or hemorrhagic stroke while on anticoagulation therapy, either during the perioperative period or in the long-term follow-up; 1 patient died of an unrelated condition. The mean follow-up was 16.4 months.

CONCLUSIONS

Results of this study suggest that initial anticoagulation for symptomatic ICAT leads to a low rate of recurrent ischemic events and that carotid revascularization, if indicated, can be safely performed in a delayed manner.

Diagnostic yield of catheter angiography in patients with subarachnoid hemorrhage and negative initial noninvasive neurovascular examinations

BACKGROUND AND PURPOSE

The yield of DSA in patients with SAH and negative initial noninvasive neurovascular examinations (CTA or MRA) is not well-understood. This study aimed to determine the yield of DSA for the detection of causative vascular lesions in this clinical scenario.

MATERIALS AND METHODS

We examined the yield of DSA for the detection of causative vascular lesions in a cohort of patients presenting to our institution with SAH and negative initial noninvasive neurovascular examinations during a 5-year period. Two experienced neuroradiologists independently evaluated the NCCT to determine the SAH pattern (diffuse, perimesencephalic, or peripheral sulcal) and the catheter angiograms to assess the presence of a causative vascular lesion.

RESULTS

Fifty-five patients were included in the study, with a mean age of 58.2 years (median, 58 years; range, 25-88 years). Twenty-eight patients were men (50.9%), and 27 were women (49.1%). The initial noninvasive examination was a CTA in 47 patients (85.5%) and an MRA in 8 patients (14.5%). Thirty-three patients had diffuse SAH (60%); 11, perimesencephalic SAH (20%); and 11, peripheral sulcal SAH (20%). DSA demonstrated a causative vascular lesion in 6 patients (10.9%), 5 of whom had diffuse SAH (yield of 15.2%) and 1 of whom had peripheral sulcal SAH (yield of 9.1%). No causative vascular lesions were found in patients with perimesencephalic SAH.

CONCLUSIONS

DSA is a valuable tool in the evaluation of patients with diffuse and peripheral sulcal SAH who have negative initial noninvasive neurovascular examinations, demonstrating a causative vascular lesion in 15.2% and 9.1% of patients, respectively.

Pipeline embolization device and subsequent vessel sacrifice for treatment of a bleeding carotid pseudoaneurysm at the skull base: a case report

An attempt at parent vessel reconstruction with Pipeline embolization devices to treat a mycotic pseudoaneurysm of the internal carotid artery at the skull base is presented. A 50-year-old woman with malignant otitis externa and bilateral temporal bone osteomyelitis presented with brisk bleeding from her left ear. She had bony dehiscence of the left carotid canal at CT and extravasation from a pseudoaneurysm of the carotid petrous segment at angiography. Carotid tortuosity proximally precluded placing a covered stent. After the lesion stopped bleeding spontaneously and given the presence of bilateral osteomyelitis putting the contralateral carotid at risk, the decision was made to attempt preservation of the parent vessel with flow diversion. However, bleeding recurred after 12 days, necessitating carotid sacrifice. This first reported experience in treating a carotid pseudoaneurysm at the skull base with the Pipeline device shows that transient cessation of bleeding is insufficient for flow diversion to be effective.

Hemorrhagic complications after prasugrel (Effient) therapy for vascular neurointerventional procedures

INTRODUCTION

Dual antiplatelet therapy (DAPT) with aspirin and a thienopyridine (eg, clopidogrel) prevents stent related thromboembolic events in cardiac patients and is frequently utilized during neurointerventional surgery. However, recent data suggest that many patients exhibit clopidogrel resistance. Prasugrel-a newer thienopyridine-lowers the rate of cardiac stent thromboses in clopidogrel non-responders but a paucity of data exist regarding its safety and efficacy in neurointerventional surgery.

METHODS

All patients undergoing neurointerventional surgery by a single interventionalist (CJM) over a 20 month period were retrospectively identified. Charts were reviewed for pre- and post-procedural DAPT regimens, pre-procedural coagulation parameters and procedural complications.

RESULTS

76 patients received pre- and post-procedural DAPT for endovascular treatment of an intracerebral aneurysm, dural arteriovenous fistula or intra/extracranial arterial stenosis. 51 patients underwent 55 total procedures and were treated with aspirin/clopidogrel; 25 patients underwent 31 total procedures and were treated with aspirin/prasugrel. Those patients who received aspirin/prasugrel DAPT were identified pre-procedurally to be clopidogrel non-responders. Both treatment groups had a similar percentage of patients undergoing aneurysm coiling, stent assisted aneurysm coiling, aneurysm Onyx embolization, aneurysm pipeline embolization device treatment, extra/intracranial carotid artery angioplasty and stenting, and dural arteriovenous fistula coil embolization. A total of eight (9.3%) hemorrhagic complications were observed, two (3.6%) in the aspirin/clopidogrel group and six (19.4%) in the aspirin/prasugrel group (p=0.02). No differences were noted in hemorrhage rates for each procedure between treatment groups, nor were there any differences in thrombotic complications between groups.

CONCLUSION

Our results suggest that DAPT with aspirin/prasugrel may predispose to a higher risk of hemorrhage during neurointerventional surgery compared with DAPT with aspirin/clopidogrel.

Yield of catheter angiography in patients with intracerebral hemorrhage with and without intraventricular extension

BACKGROUND AND AIM

The role of imaging for the detection of vascular lesions in patients with intracerebral hemorrhage (ICH) is poorly defined. A study was undertaken to compare the yield of digital subtraction angiography (DSA) in patients with ICH with intraventricular hemorrhage (IVH) and those without IVH.

METHODS

The DSA database at our institution was reviewed for patients who underwent DSA for acute spontaneous ICH over a period of 68 months. Patients with known vascular malformation or brain neoplasm, prior surgery, ischemic infarction, subarachnoid hemorrhage or isolated IVH were excluded. Patients were grouped into those with associated IVH (group A) and those without (group B). Baseline demographic and clinical data, non-contrast head CT (NCCT) probability for a vascular lesion and angiographic results were compared.

RESULTS

293 patients met the inclusion and exclusion criteria (141 women, 152 men, mean age 57, range 18-88), 139 in group A and 154 in group B. Age and sex distributions were similar (p>0.05). Group A patients were more likely to be hypertensive or coagulopathic (p=0.001). Group B had more patients with high probability NCCT scans (p<0.001). Underlying vascular lesions were found in 21 patients (15.1%) in group A and 34 (22.1%) in group B (p>0.05).

CONCLUSION

The presence of IVH in patients with acute spontaneous ICH is not associated with an increased risk of an underlying vascular lesion and should not be used to select patients for neurovascular evaluation.

Outcomes of angioplasty and stenting at the common carotid origin

BACKGROUND

Conventional treatment of stenosis at the common carotid artery origin has involved extra-anatomic bypass using an open cervical approach or median sternotomy. The goal of this study is to determine the procedural feasibility and safety of angioplasty and stenting at the common carotid origin as a less invasive alternative.

METHODS

Between March 1996 and November 2005, a total of 248 carotid angioplasty and/or stenting procedures were performed at our institution. Of these, 8 procedures were performed in 7 patients for treatment of a stenosis or dissection located at the common carotid origin. There were 4 males and 3 females with a mean age of 58 (range, 22-77). Five patients presented with neurologic symptoms. The patients' medical records were retrospectively reviewed for imaging reports (cerebral angiography, computed tomography, or ultrasound) and available clinical follow-up. Brief telephone interviews with patients, immediate family, or care personnel were also used. Procedural and midterm complication rates were calculated.

RESULTS

Of 8 procedures, 7 (87.5%) resulted in no residual stenosis. The procedural stroke rate was 0 (0%) of 8 procedures. The procedural TIA rate was 2 (25%) of 8 procedures. The mean follow-up was 31.7 months (range, 11.3-75.9 months). In 2 cases, follow-up was clinical only. In the remaining cases, there were clinical and imaging follow-up in the form of cerebral angiography (n = 3), CT angiography (n = 2), and ultrasound (n = 1). There was one recurrent TIA at 30 days and again at 3.1 months (1/8, 12.5%). There were no strokes (0/8, 0%) and there were no TIAs in patients who were initially asymptomatic on presentation. There was one death from an unrelated cause.

CONCLUSION

In this series, angioplasty and stenting were effective in relieving stenosis at the common carotid origin and have low rates of ischemic complications.

Carotid angioplasty and stenting in the elderly

INTRODUCTION

To investigate the technical success rate as well as the procedural and mid-term complication rates of carotid angioplasty and stenting in elderly patients, a group excluded from large randomized endarterectomy trials given their perceived high surgical risk.

METHODS

Of 200 consecutive carotid angioplasty and/or stenting procedures performed between March 1996 and March 2005, 21 procedures were performed without cerebral protection devices in 20 patients over the age of 79 years (mean age: 83 years, 12 men, eight women). These patients' medical records were retrospectively reviewed for vascular imaging reports and available clinical follow-up. Procedural and mid-term complication rates were calculated and compared to a previously published cohort of 133 consecutive patients < or = 79 years of age who also underwent endovascular treatment at our institution.

RESULTS

Carotid stenosis was reduced from a mean of 82% to no significant stenosis in all procedures. The procedural stroke rate was zero of 21 procedures. The procedural transient ischemic attack rate (TIA) was one of 21 procedures (4.8%). Mean follow-up was 24.6 months (range: 1.0-79.5 months) with at least a 30-day follow-up for 20 of the 21 procedures (95.2%). There were no new strokes. There was one recurrent ipsilateral TIA at 1.9 months. In five cases with follow-up carotid ultrasonography, no hemodynamically significant restenosis had occurred. There were three myocardial infarctions (MI) occurring at 0.5, 2.1, and 15.2 months, of which the last MI was fatal. The composite 30-day stroke and death rate was zero of 21 procedures (95% confidence interval: 0-14%). No significant difference was found in the 30-day rate of stroke, TIA, MI, or death between the elderly and younger patients.

CONCLUSION

Carotid angioplasty and stenting in elderly patients can be performed successfully with acceptable procedural and mid-term complication rates comparable to younger patients.

Carotid angioplasty and stent placement for restenosis after endarterectomy

INTRODUCTION

Recurrent carotid stenosis following endarterectomy is a common complication, and reoperation may be associated with increased morbidity. The goal of this study was to determine the procedural safety and long-term complication rates of carotid angioplasty and stenting for recurrent stenosis.

METHODS

Of 248 consecutive carotid angioplasty and/or stenting procedures performed at our institution between March 1996 and November 2005, 83 procedures for recurrent stenosis following endarterectomy were performed in 75 patients (mean age 68 years; 43 men, 32 women) without cerebral protection devices. The patients' medical records were retrospectively reviewed for vascular imaging reports and available clinical follow-up. Procedural and long-term complication rates were calculated.

RESULTS

Recurrent stenosis was reduced from a mean of 80.6% to no significant stenosis in 82 of 83 procedures. The procedural stroke rate was 3 out of 83 procedures (3.6%). The procedural transient ischemic attack (TIA) rate was 2 out of 83 procedures (2.4%). Mean follow-up was 22.4 months (range 0.1 to 86.7 months) with at least 6 months follow-up for 54 of 83 procedures (65%). There were five TIAs and no strokes on follow-up (new TIAs at 25.5 and 43.4 months; recurrent TIAs at 1, 11.1, and 12 months, all with normal angiograms). The composite 30-day stroke, myocardial infarction, or death rate was 5 of 83 procedures (6.0%).

CONCLUSION

In this series, angioplasty and stenting were effective in relieving stenosis secondary to recurrent carotid disease after endarterectomy, and have low rates of ischemic complications.

Angioplasty and stenting in carotid dissection with or without associated pseudoaneurysm

BACKGROUND AND PURPOSE

Carotid angioplasty and stent placement may be the preferred treatment in patients with carotid dissection who have failed medical management. The goal of this study was to determine the procedural feasibility and safety as well as long-term complication rates of carotid angioplasty and stent placement in a consecutive cohort of relatively young, high-surgical-risk patients.

PATIENTS AND TECHNIQUES

A series of 26 consecutive patients (mean age, 49 years; 15 men and 11 women) who underwent angioplasty and stent placement for carotid dissection with or without pseudoaneurysm from April 1997 to April 2005 at our institution (9 traumatic, 8 spontaneous, and 9 iatrogenic) was retrospectively reviewed. Twenty-eight stents were used in 29 procedures performed on 27 vessels (20 internal carotid arteries and 7 common carotid arteries). Patients were followed with cerebral angiography, CT, sonography, or clinically for a mean of 14.6 months (range, 5 days to 48.2 months) with 17 of 26 patients having at least 6 months of follow-up. Procedural and long-term complication rates were calculated.

RESULTS

Dissection-induced stenosis was reduced from 71 +/- 18% to no significant stenosis in 20 of the 21 patients with measurable stenosis. The procedural transient ischemic attack (TIA) rate was 3 of 29 procedures (10.3%). There were no procedural strokes. One patient required angioplasty of a common femoral artery. One procedure was terminated when an asymptomatic new intimal flap was created before intervention. Two patients had occlusions of the treated vessel noted at 22 days (presented with contralateral stroke) and 3.4 months (asymptomatic). There were 2 unrelated deaths from myocardial infarction at 8 days and 15.2 months. Two patients had recurrent ipsilateral TIA at 2.7 months and 12 months. The 30-day occlusion and death rate was 2 of 29 procedures (6.9%).

CONCLUSION

In this series, angioplasty and stent placement were effective in relieving stenosis secondary to carotid dissection with or without pseudoaneurysm and have low rates of ischemic complications.

Outcomes of carotid angioplasty and stenting for radiation-associated stenosis

BACKGROUND AND PURPOSE

In light of their high surgical risk, carotid angioplasty and stent placement may be preferred in patients with radiation-associated carotid stenosis. The purpose of this study was to determine the procedural complication rate, patency, and clinical outcomes after carotid angioplasty and stent placement in this small group of high-risk patients.

METHODS

Sixteen patients (mean age, 65 years; 5 women and 11 men) who received radiation therapy for head and/or neck malignancy subsequently developed carotid stenosis (mean, 84%; range, 70%-99%) in a total of 19 carotid arteries, which were treated with angioplasty and stent placement. The patients were followed for a mean time of 28 months (range, 5-78 months) with periodic Doppler studies, angiography, CT angiography, or clinically.

RESULTS

In the total 19 stented carotid arteries, 23 procedures were performed (22 stent placement procedures and one repeat angioplasty). The procedural stroke rate was 1/23 (4%). The procedural transient ischemic attack rate was 0/23 (0%). There was one other observed complication: a puncture site hematoma. The 30-day postprocedure complication rate was 0/23 (0%); no neurologic symptoms were reported. Fifteen of the 19 vessels (79%) developed no new stenosis throughout the follow-up period. Two of 19 (11%) vessels had repeat angioplasty and stent placement; 1/19 (5%) had a repeat angioplasty. One restented vessel has remained patent for 50 months. Another restented vessel required a third stent placement 17 months after the second. Two of 19 (11%) vessels occluded per Doppler examination 14 and 22 months postprocedure.

CONCLUSION

Angioplasty and stent placement have low rates of complications and restenosis in the treatment of radiation-associated carotid occlusive disease.

Procedure complications of carotid angioplasty and stent placement without cerebral protection devices

Object

The goal in this retrospective study was to examine the procedural complication rate for carotid angioplasty and stent placement performed without cerebral protection devices.

Methods

Between March 1996 and December 2003, 167 carotid angioplasty and/or stent placement procedures were performed without cerebral protection devices in 152 patients (57 women and 95 men whose mean age was 64 years, range 19–92 years). Seven of these patients underwent angioplasty alone. Eighty-nine patients presented with focal neurological symptoms. Indications for surgery included atherosclerosis, radiation-associated stenosis, dissection, pseudoaneurysm, and stretched endovascular coils from aneurysm treatment. In this study, the patients' medical records were reviewed for clinical characteristics, techniques used, and resulting intraprocedural and 30-day complication rates.

The intraprocedural stroke rate was four (2.4%) of 167; this included three hemispheric strokes and one retinal embolus. All events occurred in patients who had symptomatic stenosis. The procedural transient ischemic complication rate was six (3.6%) of 167, as was the procedural nonneurological complication rate. During the 30 days post-procedure, one patient had died and three had suffered permanent ischemic events (two cerebral and one ocular). The composite 30-day postprocedural stroke and death rate was eight (5%) of 160. The rate of asymptomatic angiographically confirmed abnormalities was 0.6% (one treated vessel that was occluded but asymptomatic). The 30-day rate of nonneurological complications was 2.5%. A strong association between intraprocedural thromboembolic events (eight cases) and prior ischemic symptoms was found (p = 0.01).

Conclusions

Carotid angioplasty and stent placement without cerebral protection devices is safe, particularly in patients without symptomatic stenosis.

Primary angiitis of the central nervous system at conventional angiography

PURPOSE

To retrospectively determine the sensitivity and specificity of cerebral angiography for the diagnosis of primary angiitis of the central nervous system (CNS).

MATERIALS AND METHODS

Institutional review board approval was obtained, and informed consent was not required. Thirty-eight patients (13 men, 25 women; mean age, 55 years) had undergone cerebral angiography followed by cortical and leptomeningeal biopsy for possible primary angiitis of the CNS during an 8-year period. Angiography reports were reviewed by investigators blinded to the results of biopsy. Angiographic findings were categorized as typical for vasculitis, normal, or other. Sensitivity and specificity of cerebral angiography for the diagnosis of primary angiitis of the CNS were calculated.

RESULTS

Fourteen patients had typical angiographic findings of vasculitis. None had primary angiitis of the CNS at brain biopsy (60% specificity). Specific pathologic diagnoses other than primary angiitis of the CNS were made in six patients. Findings of brain biopsy in the remaining eight patients were nondiagnostic. Repeat angiograms were obtained in three of the eight patients. One patient demonstrated interval improvement in multiple focal intracranial arterial stenoses and two demonstrated worsening. Primary angiitis of the CNS was found at biopsy in two of the remaining 24 patients (0% sensitivity). One of the two patients had slow filling of a single distal cortical artery, and the other patient had multiple regions of abnormally prolonged capillary blush.

CONCLUSION

In this series, patients suspected of having primary angiitis of the CNS on the basis of clinical and angiographic findings did not have primary angiitis of the CNS at biopsy. Typical angiographic findings of primary angiitis of the CNS are often associated with other specific pathologic diagnoses, which emphasizes the importance of brain biopsy.