Comparison of nimodipine formulations and administration techniques via enteral feeding tubes in patients with aneurysmal subarachnoid hemorrhage: A multicenter retrospective cohort study

BACKGROUND

Nimodipine improves outcomes following aneurysmal subarachnoid hemorrhage (aSAH) and current guidelines suggest that patients with aSAH receive nimodipine for 21 days. Patients with no difficulty swallowing will swallow the whole capsules or tablets; otherwise, nimodipine liquid must be drawn from capsules, tablets need to be crushed, or the commercially available liquid product be used to facilitate administration through an enteral feeding tube (FT). It is not clear whether these techniques are equivalent. The goal of the study was to determine if different nimodipine formulations and administration techniques were associated with the safety and effectiveness of nimodipine in aSAH.

METHODS

This was a retrospective multicenter observational cohort study conducted in 21 hospitals across North America. Patients admitted with aSAH and received nimodipine by FT for ≥3 days were included. Patient demographics, disease severity, nimodipine administration, and study outcomes were collected. Safety end points included the prevalence of diarrhea and nimodipine dose reduction or discontinuation secondary to blood pressure reduction. Predictors of the study outcomes were analyzed using regression modeling.

RESULTS

A total of 727 patients were included. Administration of nimodipine liquid product was independently associated with higher prevalence of diarrhea compared to other administration techniques/formulations (Odds ratio [OR] 2.28, 95% confidence interval [CI] 1.41-3.67, p-value = 0.001, OR 2.76, 95% CI 1.37-5.55, p-value = 0.005, for old and new commercially available formulations, respectively). Bedside withdrawal of liquid from nimodipine capsules prior to administration was significantly associated with higher prevalence of nimodipine dose reduction or discontinuation secondary to hypotension (OR 2.82, 95% CI 1.57-5.06, p-value = 0.001). Tablet crushing and bedside withdrawal of liquid from capsules prior to administration were associated with increased odds of delayed cerebral ischemia (OR 6.66, 95% CI 3.48-12.74, p-value <0.0001 and OR 3.92, 95% CI 2.05-7.52, p-value <0.0001, respectively).

CONCLUSIONS

Our findings suggest that enteral nimodipine formulations and administration techniques might not be equivalent. This could be attributed to excipient differences, inconsistency and inaccuracy in medication administration, and altered nimodipine bioavailability. Further studies are needed.

Placement of a Pipeline Embolization Device: 2-Dimensional Operative Video

Flow diversion has been a game-changer in the treatment of wide-neck large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms as well as large vertebral artery aneurysms. Prior to their existence, carotid sacrifice or clipping with or without external to internal carotid artery bypass was the mainstay of treatment. Prior to flow diversion, endovascular coil embolization was often not effective as a stand-alone treatment because of the fact that many of these aneurysms present with symptoms created by mass effect on the cavernous sinus cranial nerves by the aneurysm. Packing the aneurysm with coils did nothing to alleviate the mass effect and did not prevent flow from entering the aneurysm. The continued flow causes coil compaction and aneurysm enlargement. Flow diversion addressed both these issues by diverting flow from the aneurysm while allowing the aneurysm to slowly thrombose and shrink. The video is a step-by-step account of this procedure in a 72-yr-old male with a large recurrence of a previously coiled cavernous ICA aneurysm. The procedure was performed following informed consent.

The Use of Antiplatelet Agents and Heparin in the 24-Hour Postintravenous Alteplase Window for Neurointervention

BACKGROUND

Intravenous (IV) alteplase with mechanical thrombectomy has been found to be superior to alteplase alone in select patients with intracranial large vessel occlusion. Current guidelines discourage the use of antiplatelet agents or heparin for 24 h following alteplase. However, their use is often necessary in certain circumstances during thrombectomy procedures.

OBJECTIVE

To study the safety and outcomes in patients who received blood thinning medications for thrombectomy after IV Tissue-Type plasminogen activator (tPA).

METHODS

This is a multicenter retrospective review of the use of antiplatelet agents and/or heparin in patients within 24 h following tPA administration. Patient demographics, comorbidities, bleeding complications, and discharge outcomes were collected.

RESULTS

A series of 88 patients at 9 centers received antiplatelet medications and/or heparin anticoagulation following IV alteplase for revascularization procedures requiring stenting. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 14.6. Reasons for use of a stent included internal carotid artery occlusion in 74% of patients. Thrombolysis in cerebral infarction (TICI) 2b-3 revascularization was accomplished in 90% of patients. The rate of symptomatic intracranial hemorrhage (sICH) was 8%; this was not significantly different than the sICH rate for a matched group of patients not receiving antiplatelets or heparin during the same time frame. Functional independence at 90 d (modified Rankin Scale 0-2) was seen in 57.8% of patients. All-cause mortality was 12%.

CONCLUSION

The use of antiplatelet agents and heparin for stroke interventions following IV alteplase appears to be safe without significant increased risk of hemorrhagic complications in this group of patients when compared to control data and randomized controlled trials.

Abstract P168: Who Are You Going to Call?: Emergency Physician Stroke Champions

Introduction: A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists with a projected 19% shortage by 2025. An additional supply of 3000 neurologists is needed by 2025 to meet the looming demand. To help ease the shortage, teleneurology has been implemented by neurologists, mainly for acute stroke patients. We present our model of emergency physician Stroke Champions (SCs) to direct care for stroke patients.

Methods: Administering thrombolytics for stroke is a key component of emergency medicine core competencies. Our health system consists of 4 hospitals; a main hub and 3 spoke hospitals. The hub hospital innovatively developed a Neurologic Emergency Department (Neuro ED) with 5 board certified emergency physicians dedicated to caring for patients with any type of neurological complaint. The Neuro ED physicians are also designated as SCs that have specialized training to provide teleneurology to fellow emergency physicians caring for acute stroke patients at the additional hospitals. This supplementary training consists of a mini neurology fellowship with rotations through the neurologic ICU, specialized stroke floor, neurointerventional suite, and neuroradiology.

Results: Over a 90-day period the command center received 67 phone calls for patients that met stroke alert criteria. Calls entailed managing BP, dosing alteplase, and recommendations for advanced neuroimaging. Most importantly, the SCs extensively reviewed inclusion and exclusion criteria for IV alteplase with the spoke emergency physician. Three patients were deemed eligible for IV alteplase, with no cases of intracranial hemorrhage. Seven patients required transfer and was facilitated by the SCs, reducing any delays. Reasons for transfer included 3 cases of hemorrhagic stroke, 3 large vessel occlusions for mechanical thrombectomy - one of which received IV alteplase, and 1 brain tumor.

Conclusion: Teleneurology is a reliable means of reaching and treating stroke patients. With the severe current shortage of neurologists in the U.S., we now demonstrate a promising alternative of emergency physician Stroke Champions providing telestroke care. This model has produced a high success rate raising the standard of acute neurological care.

Carotid Artery Angioplasty and Stenting: 2-Dimensional Operative Video

Carotid artery angioplasty and stenting (CAS) has been shown to be equally effective as carotid endarterectomy (CEA) for carotid stenosis in both symptomatic and asymptomatic disease.1 In patients who are considered high risk for endarterectomy, CAS is safe and effective.2 While this is a common procedure, proper technique is crucial to ensure that the procedure is safe with minimal risk of stroke. This patient consented to treatment. The following is a video detailing the CAS procedure in a 77-yr-old male with a symptomatic 65% carotid stenosis (by NASCET criteria3) in a patient with prior CEA.

Common Femoral Artery Access: 2-Dimensional Operative Video

Vascular access for cerebral angiography has traditionally been performed via the common femoral artery. It is crucial to obtain safe access to prevent complications that could lead to limb ischemia, groin hematoma, or retroperitoneal hematoma. This is especially true in neurointervention as many patients are anticoagulated or have received intravenous thrombolytics prior to their intervention. Special attention to anatomic landmarks, both grossly and radiographically, can help to assure safe access. The patient consented for this procedure. This video details rapid but safe femoral artery access in a patient undergoing emergent thrombectomy.

Endovascular Coil Embolization of a Posterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Since the International Subarachnoid Aneurysm Trial,1 endovascular treatment has been the favored treatment for appropriate ruptured intracranial aneurysms. While our endovascular technology has advanced to allow us to treat the majority of intracranial aneurysms, simple coil embolization is still the most common modality. This video demonstrates the fundamentals of aneurysm catheterization and coiling for safe treatment. In addition, the set-up and devices are detailed. This video is to add to the library of basic techniques that will aid a large number of practitioners. This patient consented to endovascular treatment. The video demonstrates endovascular coil embolization of a posterior communicating artery aneurysm in a 76-yr-old female who presented with a subarachnoid hemorrhage. Image of biplane suite in video used courtesy of Siemens Medical Solutions USA, Inc. Illustration at 5:12 reprinted from Yasargil MG, et al, Microneurosurgery IV B, p. 9, Thieme, New York, 1995.

Delayed presentation of acute ischemic strokes during the COVID-19 crisis

BACKGROUND

The COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US.

METHODS

The interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020.

RESULTS

There were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, P<0.02).

CONCLUSION

We present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center.

Minimizing SARS-CoV-2 exposure when performing surgical interventions during the COVID-19 pandemic

BACKGROUND

Infection from the SARS-CoV-2 virus has led to the COVID-19 pandemic. Given the large number of patients affected, healthcare personnel and facility resources are stretched to the limit; however, the need for urgent and emergent neurosurgical care continues. This article describes best practices when performing neurosurgical procedures on patients with COVID-19 based on multi-institutional experiences.

METHODS

We assembled neurosurgical practitioners from 13 different health systems from across the USA, including those in hot spots, to describe their practices in managing neurosurgical emergencies within the COVID-19 environment.

RESULTS

Patients presenting with neurosurgical emergencies should be considered as persons under investigation (PUI) and thus maximal personal protective equipment (PPE) should be donned during interaction and transfer. Intubations and extubations should be done with only anesthesia staff donning maximal PPE in a negative pressure environment. Operating room (OR) staff should enter the room once the air has been cleared of particulate matter. Certain OR suites should be designated as covid ORs, thus allowing for all neurosurgical cases on covid/PUI patients to be performed in these rooms, which will require a terminal clean post procedure. Each COVID OR suite should be attached to an anteroom which is a negative pressure room with a HEPA filter, thus allowing for donning and doffing of PPE without risking contamination of clean areas.

CONCLUSION

Based on a multi-institutional collaborative effort, we describe best practices when providing neurosurgical treatment for patients with COVID-19 in order to optimize clinical care and minimize the exposure of patients and staff.

First Pass Effect in Patients Treated With the Trevo Stent-Retriever: A TRACK Registry Study Analysis

Background and Objective: The first pass effect (FPE; achieving complete recanalization with a single thrombectomy device pass) has been shown to be associated with higher rates of good clinical outcomes in patients with acute ischemic stroke. Here, we investigate clinical and radiographic factors associated with FPE in a large U.S. post-marketing registry (TRACK, Trevo Stent-Retriever Acute Stroke).

Methods: We analyzed the TRACK database (multicenter registry of 634 patients from 23 centers from March 2013 through August 2015), which 609 patients were included in the final analysis. FPE was defined as a single pass/use of device, TICI 2c/3 recanalization, and no use of rescue therapy. Analysis of individual patient data from TRACK were performed to analyze clinical and radiographic characteristics associated with FPE as well-compared clinical outcomes defined as modified Rankin Scale (mRS) score at 30 and 90 days from hospital discharge to the non-FPE group.

Results: The rate of FPE in TRACK was 23% (140/609). There was no association between patient demographics and FPE, including age (p = 0.36), sex (p = 0.50), race (p = 0.50), location of occlusion (p = 0.26), baseline NIHSS (p = 0.62), or past medical history. There was no difference in the use of a balloon-guide catheter or general anesthesia (49 and 57% with FPE vs. 47 and 64%, p = 0.63 and p = 0.14, respectively). Clinical outcomes were significantly associated with FPE; 63 vs. 44% in non-FPE patients achieved mRS 0–2 at 90 days (p = 0.0004).

Conclusion: Our study showed that achieving complete recanalization with a single thrombectomy pass using the Trevo device was highly beneficial. The most common clinical factors that are used to determine eligibility for endovascular therapy, such as NIHSS severity, location of occlusion or patient age were not predictive of the ability to achieve FPE.

Trevo 2000: Results of a Large Real-World Registry for Stent Retriever for Acute Ischemic Stroke

Background Recent randomized controlled trials show benefit of thrombectomy for large vessel occlusion in stroke. Real-world data aid in assessing reproducibility of outcomes outside of clinical trials. The Trevo Retriever Registry is a multicenter, international, prospective study designed to assess outcomes in a large cohort of patients. Methods and Results The Trevo Registry is a prospective database of patients with large vessel occlusion treated with the Trevo device as the first device. The primary end point is revascularization based on modified Thrombolysis in Cerebral Infarction score and secondary end points include 90-day modified Rankin Scale, 90-day mortality, neurological deterioration at 24 hours, and device/procedure related adverse events. Year 2008 patients were enrolled at 76 centers in 12 countries. Median admission National Institutes of Health Stroke Scale was 16 (interquartile range, 11-20). Occlusion sites were internal carotid artery (17.8%), middle cerebral artery (73.5%), posterior circulation (7.1%), and distal vascular locations (1.6%). A modified Thrombolysis in Cerebral Infarction 2b or 3 was achieved in 92.8% (95% CI, 91.6, 93.9) of procedures, with 55.3% (95% CI, 53.1, 57.5) of patients achieving modified Rankin Scale ≤2 at 3 months. Patients meeting revised 2015 American Heart Association criteria for thrombectomy had a 59.7% (95% CI , 56.0; 63.4) modified Rankin Scale 0 to 2 at 3 months, whereas 51.4% treated outside of American Heart Association criteria had modified Rankin Scale 0 to 2. 51.4% (95% CI , 49.6, 55.4). Symptomatic intracranial hemorrhage rate was 1.7% (95% CI , 1.2, 2.4). Conclusions The Trevo Retriever Registry represents real-world data with stent retriever. The registry demonstrates similar reperfusion rates and outcomes in the community compared with rigorous centrally adjudicated clinical trials. Future subgroup analysis of this cohort will assist in identifying areas of future research. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 02040259.

Innovations in Care Delivery of Stroke from Emergency Medical Services to the Neurointerventional Operating Room

Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. Here, we review our unique model of efficient care centered in our innovative Neurological Emergency Department (Neuro ED). The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.

Effect of balloon guide catheter on clinical outcomes and reperfusion in Trevo thrombectomy

Introduction

The Solitaire stent retriever registry showed improved reperfusion, faster procedure times, and better outcome in acute stroke patients with large vessel occlusion treated with a balloon guide catheter (BGC) and Solitaire stent retriever compared with a conventional guide catheter. The goal of this study was to evaluate whether use of a BGC with the Trevo stent retriever improves outcomes compared with a conventional guide catheter.

Methods

The TRACK registry recruited 23 sites to submit demographic, clinical, and site adjudicated angiographic and outcome data on consecutive patients treated with the Trevo stent retriever. BGC use was at the discretion of the physician.

Results

536 anterior circulation patients (of whom 279 (52.1%) had BGC placement) were included in this analysis. Baseline characteristics were notable for younger patients in the BGC group (65.4±15.3 vs 68.1±13.6, P=0.03) and lower rate of hypertension (72% vs 79%, P=0.06). Mean time from symptom onset to groin puncture was longer in the BGC group (357 vs 319 min, P=0.06).Thrombolysis in Cerebral Infarction 2b/3 scores were higher in the BGC cohort (84% vs 75.5%, P=0.01). There was no difference in reperfusion time, first pass effect, number of passes, or rescue therapy. Good clinical outcome at 3 months was superior in patients with BGC (57% vs 40%; P=0.0004) with a lower mortality rate (13% vs 23%, P=0.008). Multivariate analysis demonstrated that BGC use was an independent predictor of good clinical outcome (OR 2; 95% CI 1.3 to 3.1, P=0.001).

Conclusions

In acute stroke patients presenting with anterior circulation large vessel occlusion, use of a BGC with the Trevo stent retriever resulted in improved reperfusion, improved clinical outcome, and lower mortality.

Abstract WMP6: Predictors of Times to Reperfusion in the TRACK Trevo Stent-retriever Registry

Background: Time to mechanical thrombectomy is a significant driver of outcomes in acute ischemic stroke (AIS) patients presenting with large vessel occlusion (LVO). We aimed to evaluate predictors of onset to groin puncture (OTG), groin puncture to reperfusion (GTR), and onset to reperfusion (OTR) times in AIS patients treated with the Trevo stent-retriever.

Methods: The investigator-initiated TRACK registry recruited 23 clinical sites to submit demographic, clinical, site-adjudicated angiographic, and outcome data on consecutive patients treated with the Trevo device. We included patients treated <8 hours from last known normal (LKN). Times for LKN, groin puncture, and TICI 2b/3 reperfusion were available to calculate OTG, GTR, and OTR times. Using multivariable linear regression, we evaluated potential predictors of times including demographics, risk factors, baseline NIHSS score, intravenous tPA use, inter-facility transfer, perfusion imaging selection, type of anesthesia, location of LVO, use of rescue intra-arterial therapies, and number of passes.

Results: Among 433 patients analyzed (mean age 66.8 +/- 14.6 years; median NIHSS score 18; 88% anterior circulation), the median times were: OTG 240, GTR 64, and OTR 321 minutes. In multivariable analysis (Table), the independent predictors were: 1) OTG: transfer status and general anesthesia (GA) use; 2) GTR: 1 pass attempt only, use of rescue therapy, GA use, and baseline mRS >1; and 3) OTR: transfer status, use of perfusion imaging, anterior circulation LVO, use of rescue therapy, and 1 pass attempt only.

Conclusions: Major pre-treatment contributors to delays to reperfusion in AIS patients treated <8 hours in the TRACK registry included inter-facility transfer (+82.5 minutes) and use of perfusion imaging (+30.6 minutes). Reducing inter-facility transfer delays, direct transport to thrombectomy-capable hospitals, and minimizing perfusion imaging would have major impact on reducing treatment times.

Abstract 109: Trevo 2000: Results of the Largest Real-World Registry for Stent Retriever for Acute Ischemic Stroke

Objective: The Trevo Registry was designed to assess real world outcomes of the Trevo Retriever in patients experiencing ischemic stroke. It is the largest prospective study for acute stroke intervention, with 2010 patients enrolled and 90 day outcomes in 1873 patients. The primary endpoint is revascularization status based on post-procedure TICI score and secondary endpoints include 90-day mRS, 90-day mortality, neurological deterioration at 24 hours and device/procedure related adverse events.

Methods: The study was a prospective, open-label, consecutive enrollment, multi-center, international registry of patients who underwent mechanical thrombectomy for acute stroke using the Trevo stent retriever as the initial device.

Results: The median NIHSS at admission was 16 (IQR 11-20). Most patients (70.8%) were treated at <= 6 hours from last known normal with a median procedure time of 50 minutes (32-77). The occlusion site was M1 or M2 in 73.9%. General anesthesia was employed in 43.5% of procedures. TICI 2b or 3 revascularization was 92.8% with an average of 1.7 passes with the device. Median NIHSS at 24 hours and discharge was 6 and 4 respectively. Fifty-five percent (55.2%) of patients had mRS ≤2 at 3 months and the overall mortality rate was 13.8%. Patients treated after 8 hours of symptom onset had a 95% revascularization rate and 51.2% mRS ≤2 at 3 months. The symptomatic ICH rate was 1.6%. Patients who met the revised AHA criteria for thrombectomy were found to have 59.5% mRS 0-2 at 90 days.

Conclusions: The Trevo Retriever Registry represents the first real world data with stent retriever use in the era of clinical trials showing the overwhelming benefit of stent retrievers to treat acute ischemic stroke. Due to the fact that this data represents real world use of the Trevo Retriever, (e.g. subjects pre-stroke mRS >1 (29%) and those treated 6-24 hours after stroke symptoms (29%), this data cannot be compared to the results from recent trials with restricted eligibility criteria. Future subgroup analysis of this large cohort will help to identify areas of future research to enhance outcomes further with this treatment modality.

TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry

Background

Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice.

Methods

Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH).

Results

A total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90-day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH.

Conclusion

The TRACK Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations.

Initial Clinical Experience with AView-A Clinical Computational Platform for Intracranial Aneurysm Morphology, Hemodynamics, and Treatment Management

BACKGROUND

The management of intracranial aneurysm (IA) is challenging. Clinicians often rely on varied and intuitively disparate ways of evaluating rupture risk that may only partially take into account complex hemodynamic and morphologic factors. We developed a prototype of a clinically oriented, streamlined, computational platform, AView, for rapid assessment of hemodynamics and morphometrics in clinical settings. To show the potential clinical utility of AView, we report our initial multicenter experience highlighting the possible advantages of morphologic and hemodynamic analysis of IAs.

METHODS

AView software was deployed across 8 medical centers (6 in the United States, 2 in Japan). Eight clinicians were trained and used the AView software between September 2012 and January 2013.

RESULTS

We present 12 illustrative cases that show the potential clinical utility of AView. For all, morphology and hemodynamics, flow visualization, and rupture resemblance score (a surrogate for rupture risk) were provided. In 3 cases, AView could confirm the clinicians' decision to treat; in 3 cases, it could suggest which aneurysms may be at greater risk among multiple aneurysms; in 5 cases, AView could provide additional information for use during treatment decisions for ambiguous situations. In one stent-assisted coiling case, flow visualization predicted that the intuitive choice for stent placement could have resulted in sacrifice of an anterior cerebral artery due to blockage by coils and led clinicians to reconsider treatment plans.

CONCLUSIONS

AView has the potential to confirm decisions to treat IAs, suggest which among multiple aneurysms to treat, and guide treatment decisions. Furthermore, the flow visualization it affords can inform aneurysm treatment planning and potentially avoid poor outcomes.

Abstract WMP2: Trevo 2000: Real-World Experience in the First 1247 Patients

Objective: The Trevo Registry is designed to assess real world outcomes of the Trevo Retriever in patients experiencing ischemic stroke. This is the largest prospective study for acute stroke intervention, with 1247 patients currently enrolled and 90 day outcomes in 1021 patients. The primary endpoint is revascularization status based on post-procedure TICI score and secondary endpoints include 90-day mRS, 90-day mortality, neurological deterioration at 24 hours and device/procedure related adverse events.

Methods: The study is a prospective, open-label, consecutive enrollment, multi-center, international registry of patients undergoing mechanical thrombectomy for acute stroke using the Trevo stent retriever as the initial device. Enrollment is expected to reach 2000 subjects at up to 100 sites.

Results: As of August 13, 2016 a total of 1247 patients were enrolled. The median NIHSS at admission was 16 (IQR 11-20). Most patients (66.2%) were treated at >/= 6 hours from last known normal with a median procedure time of 50 minutes (32-77). The occlusion site was M1 or M2 in 74.5%. General anesthesia was employed in 46.6% of procedures. TICI 2b or 3 revascularization was 92.8% with an average of 1.6 passes with the device. Median NIHSS at 24 hours and discharge was 6 and 4 respectively. Fifty-five percent of patients had mRS ≤2 at 3 months and the overall mortality rate was 15.4%. Patients treated after 8 hours of symptom onset had a 94.9% revascularization rate and 52.8% mRS ≤2 at 3 months. The symptomatic ICH rate was 1.2%. Patients who met the revised AHA criteria for thrombectomy were found to have 58.4% mRS 0-2 at 90 days.

Conclusions: The Trevo Retriever Registry represents the first real world data with stent retriever use in the era of clinical trials showing the overwhelming benefit of stent retrievers to treat acute ischemic stroke. Due to the fact that this data represents real world use of the Trevo Retriever, (e.g. subjects pre-stroke mRS >1 (16.5%) and those treated 6-24 hours after stroke symptoms (33.8%), this data cannot be compared to the results from recent trials with restricted eligibility criteria. Future subgroup analysis of this large cohort will help to identify areas of future research to enhance outcomes further with this treatment modality.

Carotid Artery Angioplasty and Stenting Without Distal Embolic Protection Devices

BACKGROUND

Embolic protection devices are used during carotid artery stenting procedures to reduce risk of distal embolization. Although this is a standard procedural recommendation, no studies have shown superiority of these devices over unprotected stenting procedures.

OBJECTIVE

To assess the periprocedural outcome and durability of carotid artery stenting without embolic protection devices and poststent angioplasty.

METHODS

We performed a retrospective chart review of 174 carotid angioplasty stent procedures performed at our institution. One hundred sixty-six patients underwent angioplasty and stenting without distal protection devices or poststent angioplasty. Complications related to stenting, including procedural complications, postoperative stroke and/or myocardial infarction, and stent restenosis were analyzed.

RESULTS

One hundred thirty-five stents (78%) were performed in symptomatic patients, whereas 22% of stents were placed for asymptomatic internal carotid artery stenosis. The degree of stenosis was 80% or greater in 75% of patients and 90% or greater in 55% of patients. Following the stenting procedure, the 24-hour and 30-day rate of transient ischemic attack, intracranial hemorrhage, or ischemic stroke was 0. Three (2%) patients had a perioperative, non-ST elevation myocardial infarction. Five patients (2.8%) required treatment for restenosis (>50% stenosis from baseline), 1 of which was symptomatic.

CONCLUSION

Our data show that carotid artery stenting without the use of embolic protection devices and without postangioplasty stenting, in experienced hands, can be performed safely. Furthermore, this technique does not result in a higher degree of in-stent restenosis than series in which poststenting angioplasty is performed.

Vessel perforation during stent retriever thrombectomy for acute ischemic stroke: technical details and clinical outcomes

BACKGROUND

Vessel perforation during stent retriever thrombectomy is a rare complication; typically only single instances have been reported.

OBJECTIVE

To report on a series of patients whose stent retriever thrombectomy was complicated by intraprocedural vessel perforation and discuss its potential mechanisms, rescue treatment strategies, and clinical significance.

METHODS

Cases with intraprocedural vessel perforation, where a stent retriever was used either as a primary treatment approach or as a part of a direct aspiration first pass technique (ADAPT), were included in the final analysis. Clinical data, procedural details, radiographic and clinical outcomes were collected from nine participating centers.

RESULTS

Intraprocedural vessel perforation during stent retriever thrombectomy occurred in 16 (1.0%) of 1599 cases. 63% of intraprocedural perforations occurred at distal locations. Endovascular rescue techniques (most commonly, intracranial balloon occlusion for tamponade) were attempted in 50% of cases. Procedure was aborted without any rescue attempts in 44% of cases. Mortality during hospitalization and at 3 months was 56% and 63%, respectively. 25% of patients achieved good functional outcome at 3 months after the procedure.

CONCLUSIONS

Intraprocedural perforations during stent retriever thrombectomy were rare, but when they occurred were associated with high mortality. Perforations most commonly occurred at distal occlusion sites and were often characterized by difficulty traversing the occlusion with a microcatheter or microwire, or while withdrawing the stent retriever. Nevertheless, 25% of patients had a favorable functional outcome, suggesting that in some patients with this complication good neurological recovery is achievable.

Aneurysms with persistent patency after treatment with the Pipeline Embolization Device

The Pipeline Embolization Device (PED) was approved for the treatment of intracranial aneurysms from the petrous to the superior hypophyseal segment of the internal carotid artery. However, since its approval, its use for treatment of intracranial aneurysms in other locations and non-sidewall aneurysms has grown tremendously. The authors report on a cohort of 15 patients with 16 cerebral aneurysms that incorporated an end vessel with no significant distal collaterals, which were treated with the PED. The cohort includes 7 posterior communicating artery aneurysms, 5 ophthalmic artery aneurysms, 1 superior cerebellar artery aneurysm, 1 anterior inferior cerebellar artery aneurysm, and 2 middle cerebral artery aneurysms. None of the aneurysms achieved significant occlusion at the last follow-up evaluation (mean 24 months). Based on these observations, the authors do not recommend the use of flow diverters for the treatment of this subset of cerebral aneurysms.

An Analysis of Transient Ischemic Attack Practices: Does Hospital Admission Improve Patient Outcomes?

INTRODUCTION

Immediate treatment has been shown to decrease the recurrence of cerebrovascular accidents following transient ischemic attacks (TIA), prompting the use of a specialized neurologic emergency department (Neuro ED) to triage patients. Despite these findings, there is little evidence supporting the notion that hospital admission improves post-TIA outcomes. Through the lens of a Neuro ED, this retrospective chart review of TIA patients examines whether hospital admission improves 90-day outcomes.

MATERIALS AND METHODS

Two hundred sixty charts of patients discharged with TIA diagnosis were reviewed. These charts encompassed patients with TIA who presented to a main emergency department (ED) or Neuro ED from January 2014 to April 2015. Demographic information, admission ABCD(2) scores, admission National Institutes of Health Stroke Scale scores, and admission Modified Rankin Scale, and reason for any return visits within 90 days were collected.

RESULTS

This review shows that patients triaged by the Neuro ED were admitted at a lower rate than those seen by the standard ED. Further, patients triaged by the Neuro ED experienced lower readmission and recurrence of stroke or TIA within 90 days.

CONCLUSIONS

These results provide preliminary support for the notion that discharging appropriate TIA patients, with adequate follow-up, will not adversely affect the recurrence of TIA or stroke within 90 days.

Clinical and Procedural Predictors of Outcomes From the Endovascular Treatment of Posterior Circulation Strokes

Background and Purpose—

Patients with posterior circulation strokes have been excluded from recent randomized endovascular stroke trials. We reviewed the recent multicenter experience with endovascular treatment of posterior circulation strokes to identify the clinical, radiographic, and procedural predictors of successful recanalization and good neurological outcomes.

Methods—

We performed a multicenter retrospective analysis of consecutive patients with posterior circulation strokes, who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique [ADAPT] approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics.

Results—

A total of 100 patients were included in the final analysis (mean age, 63.5±14.2 years; mean admission National Institutes of Health Stroke Scale score, 19.2±8.2). Favorable clinical outcome at 3 months (modified Rankin Scale score ≤2) was achieved in 35% of patients. Successful recanalization and shorter time from stroke onset to the start of the procedure were significant predictors of favorable clinical outcome at 90 days. Stent retriever and aspiration thrombectomy as primary treatment approaches showed comparable procedural and clinical outcomes. None of the baseline advanced imaging modalities (magnetic resonance imaging, computed tomographic perfusion, or computed tomography angiography assessment of collaterals) showed superiority in selecting patients for thrombectomy.

Conclusions—

Time to the start of the procedure is an important predictor of clinical success after thrombectomy in patients with posterior circulation strokes. Both stent retriever and aspiration thrombectomy as primary treatment approaches are effective in achieving successful recanalization.

Endovascular treatment of cerebral venous thrombosis: Contemporary multicenter experience

Endovascular therapy of cerebral venous thrombosis using modern approaches to intracranial recanalization, such as stent retrievers and aspiration thrombectomy, is not well described. We performed a retrospective review of data for consecutive patients with venous sinus thrombosis who underwent endovascular treatment between 1 January 2010 and 31 December 2013 at participating institutions. We identified a total of 13 patients with a diagnosis of cerebral venous thrombosis. The most frequently utilized type of endovascular intervention was the Penumbra aspiration system (Penumbra Inc., Alameda, California, USA) (nine cases), followed by local infusion of tissue plasminogen activator (bolus and/or drip in six cases) and stent retrievers (Solitaire FR (Covidien, Irvine, California, USA) in three cases and Trevo (Stryker, Kalamazoo, Michigan, USA) in one case). Overall, multimodality treatment (two or more different types of devices or approaches) was performed in 62% of cases. Follow-up data were available for 11 patients; of those, five had a favorable clinical outcome (defined as modified Rankin Scale score of 0-2) and three patients died. Various endovascular approaches are utilized in current clinical practice. A multimodal approach to endovascular therapy for the treatment of cerebral venous thrombosis resulted in partial or complete restoration of flow in all cases, yet the mortality rate of 27% indicates the need for improvement in recanalization strategies for this disorder.

Endovascular therapy of wake-up strokes in the modern era of stent retriever thrombectomy

Background

Endovascular treatment of wake-up strokes (WUS) has been previously described, mostly with the use of pharmacological thrombolysis or first generation thrombectomy devices.

Objective

To describe outcomes of WUS treated with modern endovascular therapy since the Food and Drug Administration approval of stent retrievers, and to identify predictors of good clinical outcome in this population of stroke patients.

Methods

We performed a multicenter retrospective analysis of consecutive patients with WUS who underwent thrombectomy with stent retrievers Trevo (Stryker, Kalamazoo, Michigan, USA) and Solitaire FR (Covidien, Irvine, California, USA), or primary aspiration thrombectomy. We correlated favorable clinical outcomes with demographic, clinical, and technical characteristics.

Results

52 patients were included in this study; 46 (88%) cases were treated with stent retrievers and 6 (12%) were treated with primary aspiration thrombectomy alone. Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b/3) was achieved in 36 (69%) patients. Favorable clinical outcome at 3 months, defined as a modified Rankin Scale score of 0–2, was achieved in 25 (48%) patients. Duration of intervention <30 min and its success, defined as TICI 2b/3 recanalization, were strong predictors of favorable clinical outcome at 90 days (p<0.001 and p<0.0001, respectively).

Conclusions

Our study indicates that endovascular treatment of WUS with stent retrievers and aspiration thrombectomy is safe and effective.

The neurological emergency room and prehospital stroke alert: the whole is greater than the sum of its parts

BACKGROUND

Emergency medical services (EMS) prenotification to hospitals regarding the arrival of patients who have had a stroke is recommended to facilitate the workup once the patient arrives. Most hospitals have the patient enter the emergency department (ED) before obtaining a head computed tomography (CT) scan. At Capital Health, prehospital stroke-alert patients are delivered directly to CT and met by a neurological emergency team. The goal of bypassing the ED is to reduce the time to treatment.

OBJECTIVE

To evaluate (1) door-to-CT and door-to-needle time in patients with an acute stroke who arrive as prehospital stroke alerts and (2) the accuracy of EMS assessment.

METHODS

A prospective database of all prehospital stroke alert patients was kept and data retrospectively reviewed for patients who were seen between July 2012 and July 2013.

RESULTS

Between July 2012 and July 2013, 141 prehospital stroke alerts were called to our emergency department, and the patients were stable enough to bypass the ED and go directly to CT. EMS assessment of stroke was accurate 66% of the time, and the diagnosis was neurological 89% of the time. The average time between patient arrival and acquisition of CT imaging was 11.8 minutes. Twenty-six of the 141 patients (18%) received intravenous tissue plasminogen activator. The median time from arrival to intravenous tissue plasminogen activator bolus was 44 minutes.

CONCLUSION

Trained EMS responders are able to correctly identify patients who are experiencing neurological/neurosurgical emergencies and deliver patients to our comprehensive stroke center in a timely fashion after prenotification. The prehospital stroke alert protocol bypasses the ED, allowing the patient to be met in CT by the neurological ED team, which has proven to decrease door-to-CT and door-to-needle times from our historical means.

ABBREVIATIONS

ASLS, Advanced Stroke Life SupportDTN, door-to-needleED, emergency departmentEMS, emergency medical servicesEMT, emergency medical technicianIV, intravenousMEND, Miami Emergency Neurological DeficitPHSA, prehospital stroke alerttPA, tissue plasminogen activator.

Utilization of Pipeline embolization device for treatment of ruptured intracranial aneurysms: US multicenter experience

OBJECTIVE

Utilization of the Pipeline embolization device (PED) in complex ruptured aneurysms has not been well studied. We evaluated the safety and effectiveness data from five participating US centers.

METHODS

Records of patients with ruptured cerebral aneurysms who underwent PED treatment between 2011 and 2013 were retrospectively reviewed.

RESULTS

26 patients with ruptured aneurysms underwent PED treatment (mean age 51.4 ± 13.2 years;16 women). At presentation, 8 patients (30.8%) had a Hunt-Hess grade of IV or above; 11 required extraventricular drain placement. Aneurysm morphologies were: 8 dissecting, 8 blister-like, 6 fusiform, and 4 saccular. There were 22 anterior circulation and 4 posterior circulation aneurysms. PED deployment was successful in all patients, with adjunctive coiling utilized in 12. Periprocedural complications occurred in 5 (19.2%), including 3 inhospital deaths. 23 patients (88.5%) had postoperative angiography at a mean of 5.9 months: 18 aneurysms (78.3%) were completely occluded, 3 (13.0%) had residual neck filling, and 2 (8.7%) had residual dome filling. All blister-type aneurysms were completely occluded at follow-up. Clinical follow-up was available for an average of 10.1 months (range 2-21 months), with one asymptomatic in-stent stenosis and one asymptomatic thromboembolic stroke noted. Good outcome (modified Rankin Scale (mRS) score of 0-2) was achieved in 20 patients (76.9%), fair (mRS 3-4) in 3 (11.5%), and 3 died (11.5%).

CONCLUSIONS

The PED can be utilized for ruptured aneurysms and is a good option for blister-type aneurysms. However, due to periprocedural complications, it should be reserved for lesions that are difficult to treat by conventional clipping or coiling.

Recombinant factor VIIa use in patients presenting with intracranial hemorrhage

Recombinant factor VIIa (rFVIIa) can be used for rapid INR normalization in life-threatening hemorrhage in anticoagulated patients. Dosing is unclear and may carry thromboembolic risks. We reviewed the use of rFVIIa at a comprehensive stroke and cerebrovascular center to evaluate dose effectiveness on INR reduction and thromboembolic complications experienced. The primary endpoint was to review the efficacy of rFVIIa in lowering INR. Secondary endpoints included doses used and adverse effects caused by rFVIIa administration. Forty-one percent of patients presented with a subdural hemorrhage. The mean INR prior to rFVIIa administration was 3.5 (0.9-15) and decreased to 1.13 (0.6-2). The mean dose of rFVIIa given was 73 mcg/kg (±24 mcg/kg). Two patients (3%) experienced a thromboembolic event. Recombinant factor VIIa appears to lower INR without significant thromboembolic complications.

Early Postmarket Experience After US Food and Drug Administration Approval With the Trevo Device for Thrombectomy for Acute Ischemic Stroke

BACKGROUND:

TREVO 2 showed the Trevo stent retriever to be more successful for revascularization than Merci for acute stroke intervention in patients treated within 8 hours of symptom onset. These results led to US Food and Drug Administration approval of Trevo.

OBJECTIVE:

To report the first postmarket experience with Trevo since US Food and Drug Administration approval at a single high-volume comprehensive stroke center in the United States.

METHODS:

A retrospective analysis of prospectively collected data was conducted in patients who underwent intervention for ischemic stroke with the Trevo device. Trevo was used alone or in conjunction with other intra-arterial devices. Two groups of patients were identified: those with symptom onset within (group 1) and those with symptom onset beyond (group 2) 8 hours. Recanalization, outcome, symptomatic intracranial hemorrhage, and in-hospital and 90-day mortality were assessed.

RESULTS:

Fifty-two patients were identified, 27 in group 1 and 25 in group 2. Thrombolysis in Cerebral Infarction grade 2 to 3 revascularization was achieved in 93% of group 1 and 84% of group 2 patients. In-hospital mortality and symptomatic intracranial hemorrhage rates were 3.8% and 12% for groups 1 and 2, respectively. Ninety-day mortality was 15% and 24% for groups 1 and 2, respectively. In groups 1 and 2, 48% and 42% of patients, respectively, had good outcomes (modified Rankin Scale score, 0–2), and 50% in both groups of patients achieved Thrombolysis in Cerebral Infarction grade 3 revascularization. Group 2 had longer revascularization times and required adjuvant devices more frequently.

CONCLUSION:

Our postmarket experience shows that in highly selected patients Trevo is safe and effective, even beyond 8 hours, despite longer procedure times and the need for adjuvant devices.

Abstract T MP41: Early Mobilization in Aneurysmal Subarachnoid Hemorrhage Accelerates the Recovery of Function

Background and Purpose: Survivors of aneurysmal subarachnoid hemorrhage (SAH) are faced with a complicated recovery that typically includes surgery, prolonged monitoring in intensive care and treatment focusing on the prevention of complications. Aware of the complications resulting from bed rest and immobility, our multidisciplinary neurocritical care team developed an early mobilization program for patients with aneurysmal SAH. The purpose of this study was to determine the effects of early mobilization on patient function and participation in rehabilitation.

Methods: A retrospective analysis was conducted on 93 patients diagnosed with aneurysmal SAH. Fifty-five patients received early mobilization after aneurysm treatment by a physical therapist or occupational therapist in the neurosurgical intensive care unit. Early mobilization focused on functional training and therapeutic exercise in progressively upright positions. Participation criteria ensured neurologic and physiologic stability prior to the initiation of early mobilization program sessions. Outcomes were compared to a control group of 38 patients that received care prior to the implementation of the early mobilization program. Data was analyzed using an independent two-tailed t- test. A p value of less than .05 was accepted as significant.

Results: Demographic and clinical characteristics between the two groups were similar (p>.05). The number of days from admission to participation in out of bed activity decreased in the early mobilization group ( =4.2) compared to the control group ( =6.4, p=.039). The number of days from admission to walking (50 feet or greater) decreased in the early mobilization group ( =6.4) compared to the control group ( =10.5, p=.004). A greater number of sessions that included out of bed activity were observed in the early mobilization group ( =6.5) compared to the control group ( =4.4, p=.013). An increase in the number of sessions that included walking (50 feet or greater) was observed in the early mobilization group but was not significant.

Conclusion: Patients with aneurysmal SAH receiving early mobilization participated in out of bed and walking activity faster and achieved a higher level of function during rehabilitation sessions.

Endovascular Advances for Intracranial Occlusive Disease

Stroke is the fourth leading cause of death in the United States. Intracranial atherosclerotic disease accounts for 8%-10% of ischemic stroke in the United States. So far, surgical bypass has not proved to be superior to medical therapy. As both medical and endovascular therapies for intracranial atherosclerosis evolve, so too do the guidelines for treatment. Initial reports on the results of stent placement for symptomatic high-grade intracranial atherosclerotic disease were encouraging; however, recent trials suggest that initial medical management may be preferable. Currently, intracranial angioplasty and stenting for symptomatic intracranial atherosclerosis is now more controversial. Further trials are necessary to help determine which patients are ideal for endovascular therapies.

Solitaire Flow Restoration thrombectomy for acute ischemic stroke: retrospective multicenter analysis of early postmarket experience after FDA approval

BACKGROUND

The promising results of the Solitaire Flow Restoration (FR) With the Intention for Thrombectomy (SWIFT) trial recently led to Food and Drug Administration (FDA) approval of the Solitaire FR stent retriever device for recanalization of cerebral vessels in patients with acute ischemic stroke.

OBJECTIVE

To report the early postmarket experience with this device since its FDA approval in the United States, which has not been previously described.

METHODS

We conducted a retrospective analysis of consecutive acute ischemic strokes cases treated between March 2012 and July 2012 at 10 United States centers where the Solitaire FR was used as a single device or in conjunction with other intraarterial endovascular approaches.

RESULTS

A total of 101 patients were identified (mean age, 64.7 years; mean admission National Institutes of Health Stroke Scale [NIHSS] score, 17.6). Intravenous thrombolysis was administered in 39% of cases; other endovascular techniques were utilized in conjunction with the Solitaire FR in 52%. Successful recanalization (Thrombolysis in Myocardial Infarction 2/3) was achieved in 88%. The rate of symptomatic intracranial hemorrhage within the first 24 hours was 15%. In-hospital mortality was 26%. At 30 days, 38% of patients had favorable functional outcome (modified Rankin scale score ≤2). Severity of NIHSS score on admission was a strong predictor of poor outcome.

CONCLUSION

Our study shows that a variety of other endovascular approaches are used in conjunction with Solitaire FR in actual practice in the United States. Early postmarket results suggest that Solitaire FR is an effective tool for endovascular treatment of acute ischemic stroke.

Endovascular treatment of intracranial atherosclerotic disease

Stroke is the third leading cause of death in the United States. Intracranial atherosclerotic disease plays a role in cerebrovascular accidents, with well-characterized modifiable and nonmodifiable risk factors. Surgical bypass has so far not proved to be superior to medical therapy. Both medical and endovascular therapies for intracranial atherosclerosis have evolved since the initial off-label use of cardiac devices for its treatment. Initial reports on the results of stent placement for symptomatic high-grade intracranial atherosclerotic disease were initially encouraging. However, debate remains as to the optimal treatment of symptomatic intracranial atherosclerotic disease.

Early Postmarket Results After Treatment of Intracranial Aneurysms With the Pipeline Embolization Device

BACKGROUND:

The Pipeline embolization device (PED) is the latest technology available for intracranial aneurysm treatment.

OBJECTIVE:

To report early postmarket results with the PED.

METHODS:

This study was a prospective registry of patients treated with PEDs at 7 American neurosurgical centers subsequent to Food and Drug Administration approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Follow-up data included degree of aneurysm occlusion and delayed (&gt; 30 days after the procedure) complications.

RESULTS:

Sixty-two PED procedures were performed to treat 58 aneurysms in 56 patients. Thirty-seven of the aneurysms (64%) treated were located from the cavernous to the superior hypophyseal artery segment of the internal carotid artery; 22% were distal to that segment, and 14% were in the vertebrobasilar system. A total of 123 PEDs were deployed with an average of 2 implanted per aneurysm treated. Six devices were incompletely deployed; in these cases, rescue balloon angioplasty was required. Six periprocedural (during the procedure/within 30 days after the procedure) thromboembolic events occurred, of which 5 were in patients with vertebrobasilar aneurysms. There were 4 fatal postprocedural hemorrhages (from 2 giant basilar trunk and 2 large ophthalmic artery aneurysms). The major complication rate (permanent disability/death resulting from perioperative/delayed complication) was 8.5%. Among 19 patients with 3-month follow-up angiography, 68% (13 patients) had complete aneurysm occlusion. Two patients presented with delayed flow-limiting in-stent stenosis that was successfully treated with angioplasty.

CONCLUSION:

Unlike conventional coil embolization, aneurysm occlusion with PED is not immediate. Early complications include both thromboembolic and hemorrhagic events and appear to be significantly more frequent in association with treatment of vertebrobasilar aneurysms.

Use of the microangiographic fluoroscope for coiling of intracranial aneurysms

BACKGROUND

Neurointervention is an ever-evolving specialty with tools including microcatheters, microwires, and coils that allow treatment of pathological conditions in increasingly smaller intracranial arteries, requiring increasing accuracy. As endovascular tools evolve, so too should the imaging.

OBJECTIVE

To detail the use of microangiography performed with a novel fluoroscope during coiling of intracranial aneurysms in 2 separate patients and discuss the benefits and potential limitations of the technology.

METHODS

The microangiographic fluoroscope (MAF) is an ultra high-resolution x-ray detector with superior resolution over a small field of view. The MAF can be incorporated into a standard angiographic C-arm system for use during endovascular procedures.

RESULTS

The MAF was useful for improved visualization during endovascular coiling of 2 unruptured intracranial aneurysms, without adding significant time to the procedure. No significant residual aneurysm filling was identified post-coiling, and no complications occurred.

CONCLUSION

The MAF is a high-resolution detector developed for use in neurointerventional cases in which superior image quality over a small field of view is required. It has been used with success for coiling of 2 unruptured aneurysms at our institution. It shows promise as an important tool in improving the accuracy with which neurointerventionists can perform certain intracranial procedures.

Testing the boundaries of neurosurgical innovation … twice: an account of one patient's unique intracranial aneurysm treatment

BACKGROUND

The treatment of intracranial aneurysms has evolved over the past several decades and has profited by the ingenuity and expertise of generations of innovative neurosurgeons.

CASE DESCRIPTION

A 79-year-old man presented with symptoms related to recurrence of his previously ruptured basilar bifurcation aneurysm 35 years after undergoing the first awake hunterian ligation for the same aneurysm performed by Dr. Charles Drake.

CONCLUSIONS

This report details the treatment strategies applied in the management of the patient's aneurysm then and now, offering us a glimpse into the evolution of neurosurgical treatment for basilar bifurcation aneurysms in a patient who was able to benefit from neurosurgical innovation twice in his lifetime.

Muslin-induced intracranial vasculopathic stenosis: a report of two cases

Muslin wrapping is a commonly utilized alternative technique in the treatment of aneurysms that are not amenable to direct clipping. In this case report, we describe two patients from different institutions who both required aneurysm wrapping with gauze/muslin for aneurysm reinforcement. Both patients developed an inflammatory foreign body response to muslin visible on MRI that resulted in a vasculitic stenosis. The onset of TIAs was at 6 months and 1 month postoperatively, respectively. The stenoses rapidly progressed to near occlusion despite antiplatelet therapy, and in one case, an aggressive corticosteroid regimen. One patient eventually developed leptomeningeal collateral flow that allowed tolerance of the stenosis, while the other patient required microsurgical bypass. These cases reports are the first to our knowledge that describe the adverse effects of muslin wrapping without adhesive reinforcement, as well as one of few reports to include follow-up angiographic imaging.

Use of the Outreach Distal Access Catheter for microcatheter stabilization during intracranial arteriovenous malformation embolization

The Outreach DAC is an intermediate-sized catheter designed for use with the Merci clot retriever in acute stroke. We investigated its utility as an adjunctive device during AVM pedicle embolization. In the authors' opinion, the DAC provided additional guide-catheter and microcatheter support, improved selective angiographic visualization of AVM angioarchitecture, aided microcatheter removal from its embedded position in the AVM Onyx cast, and enhanced local microcatheter control and safety, compared with embolization with the guide and microcatheter alone.

Novel multidisciplinary approach for treatment of langerhans cell histiocytosis of the skull base

Langerhans cell histiocytosis frequently manifests as lesions of the skull. The disease can present with a wide spectrum of forms, from an isolated eosinophilic granuloma to multiple lesions with diffuse systemic involvement. The authors report the case of a 12-year-old boy with a 1-month history of left temporal and periorbital pain and headaches. Noncontrast computed tomography of the head was done at the time of initial presentation and was interpreted as normal. Over the next month, the patient continued to have headaches and periorbital swelling and began having bloody discharge from his nose. Magnetic resonance imaging of the brain ordered by his pediatrician showed a lesion in the left infratemporal fossa, left orbit, and sphenoid bone. The lesion was biopsied and confirmed to be Langerhans cell histiocytosis. We describe a novel multidisciplinary approach for treatment of this tumor.