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Journal Cover Interventional Neurology  
   Full-text available via subscription Subscription journal
   ISSN (Print) 1664-9737 - ISSN (Online) 1664-5545
   Published by Karger Homepage  [104 journals]
  • Implementation of Intraoperative Neurophysiological Monitoring during
           Endovascular Procedures in the Central Nervous System
    • Abstract: Background and Objective: Intraoperative monitoring (IOM) has been used in different surgical disciplines since the 1980s. Nonetheless, regular routine use of IOM in interventional neuroradiology units has only been reported in a few centers. The aim of this study is to report our experience, 1 year after deciding to implement standardized IOM during endovascular treatment of vascular abnormalities of the central nervous system. Methods: Basic recordings included somatosensory-evoked potentials (SEPs) and motor-evoked potentials (MEPs). Corticobulbar motor-evoked potentials and flash-visual-evoked potentials were also recorded depending on the topography of the lesion. Intra-arterial provocative tests (PTs) with amobarbital and lidocaine were also performed. All patients except 1 were under total intravenous anesthesia. Clinical outcome was assessed prospectively and correlated with IOM events. Results: Twelve patients and 15 procedures were monitored during the inclusion period. Significant IOM events were detected during 3 of the 15 procedures (20%). We observed temporary MEP changes in 2 cases which resolved after interruption of the embolization or application of corrective measures, leaving no postoperative neurological deficits. In 1 case, persistent SEP and MEP deterioration was detected secondary to a frontal hematoma, resulting in mild sensory-motor deficit in the right upper extremity after the procedure. Overall, 12 PTs (4 spinal cord and 8 brain abnormalities) were performed using lidocaine and sodium amytal injections. One positive result occurred after the injection of lidocaine. No false negatives were detected. Conclusions: IOM may provide continuous real-time data about the functional status of eloquent areas and pathways of the central nervous system in patients under general anesthesia. It therefore allows us to detect early neurological damage in time to perform specific actions that may prevent irreversible neurological deficits.
      Intervent Neurol 2014;3:85-100
  • High-Flow Carotid Cavernous Fistula and the Use of a Microvascular Plug
           System: Initial Experience
    • Abstract: Purpose: We report our initial experience using a detachable microvascular plug system to occlude the internal carotid artery during endovascular treatment of high-flow carotid cavernous fistula. Case and Technique: An 87-year-old patient was admitted for acute-onset double vision with associated right-eye ptosis. Exam revealed a pupil-sparing, partial right third cranial nerve palsy. MRI showed a carotid cavernous fistula with high-flow drainage. Digital subtraction angiography showed a high-flow, right-sided, direct carotid cavernous fistula with flow from the proximal right internal carotid artery. The ophthalmic artery, posterior communicating artery and anterior communicating arteries supplied retrograde flow to the fistula through the internal carotid artery. Obliteration of the fistula was achieved through coil embolization in combination with proximal and distal microvascular plugs (Reverse Medical, Irvine, Calif., USA). Conclusion: The microvascular plug is a new addition to current endovascular embolization devices for the treatment of high-flow, direct carotid cavernous fistulas. This technique offers easy navigability through tortuous arteries, precise localization and immediate occlusion, which may allow shorter procedure and fluoroscopy times and increased cost-effectiveness. Larger case series are needed to support our observation.
      Intervent Neurol 2014;3:78-84
  • The Development of Carotid Stent Material
    • Abstract: Endovascular angioplasty with stenting is a promising option for treating carotid artery stenosis. There exist a rapidly increasing number of different stent types with different materials. The bare-metal stent is the most commonly used stent with acceptable results, but it leaves us with the problems of thrombosis and restenosis. The drug-eluting stent is a breakthrough as it has the ability to reduce the restenosis rate, but the problem of late thrombosis still has to be addressed. The biodegradable stent disappears after having served its function. However, restenosis and degradation rates remain to be studied. In this article, we review every stent material with its characteristics, clinical results and complications and point out the standards of an ideal carotid stent.
      Intervent Neurol 2014;3:67-77
  • Aggressive Medical Care in Young Chinese Patients with Ischemic Stroke of
           Undetermined Etiology: A Retrospective Study
    • Abstract: Objectives: This study aimed to investigate the clinical and angiographic characteristics of ischemic stroke of undetermined etiology in young Chinese adults and to observe the effects of medication on their long-term outcomes. Methods: A total of 179 consecutive young patients with ischemic stroke of undetermined etiology were retrospectively analyzed for clinical and angiographic characteristics, laboratory tests, the choice of drug treatment, and follow-up outcomes. Any predictive power for recurrent stroke and new lesions or aggravated stenosis was analyzed. Results: 170 patients were clinically followed up for a median of 25 months (range, 4-92), and 65 patients with 114 lesions had angiographic follow-up for a median of 7 months. A total of 53 patients were enrolled in a routine medical management (RMM) group, and 117 were treated with corticosteroids plus RMM (aggressive medical management, AMM). Kaplan-Meier survival analysis revealed that differences in the 2-year cumulative stroke-free rate and in the 18-month cumulative worsening and/or new lesion-free rate between the RMM and AMM groups were significant (p < 0.05). Multivariate and Cox regression analyses revealed that the choice of drug therapy and erythrocyte sedimentation rate were associated with recurrent stroke, that AMM was independently associated with a decreased risk of worsening lesion, and that worsening lesion was the only independent predictor of recurrent stroke. Conclusion: Compared with RMM, AMM is more efficacious in the prevention of secondary ischemic stroke and progressive arterial lesions among young adults with ischemic stroke of undetermined etiology.
      Intervent Neurol 2014;3:56-66
  • Large Deep White Matter Lesions May Predict Futile Recanalization in
           Endovascular Therapy for Acute Ischemic Stroke
    • Abstract: Objective: This study investigated whether large ischemic lesions in the deep white matter (DWM) on pretreatment diffusion-weighted MRI (DWI) predict futile recanalization. Methods: Consecutive acute stroke patients with anterior circulation ischemia who underwent successful arterial recanalization with thrombolysis in cerebral infarction grade 2b or 3 were enrolled. A large DWI-DWM lesion was defined as a hyperintense lesion in the DWM on initial DWI, located mainly between the anterior and posterior horns of the lateral ventricle. The Alberta Stroke Program Early CT score on CT and DWI and stroke volume on initial DWI were recorded. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score. Futile recanalization was defined as a 30-day modified Rankin scale score of 3-6 despite successful recanalization. Univariate and multivariate regression analyses were performed to identify predictors of futile recanalization. Results: In 35 of 46 patients (76%) with successful recanalization, futile recanalization was observed in 20 patients (57%). Patients with futile recanalization were older (median age 74 vs. 58 years; p = 0.053), had higher initial NIHSS scores (median 17 vs. 9; p = 0.042), and a higher prevalence of large DWI-DWM lesions (45 vs. 9%; p = 0.022). Logistic regression analysis showed that a large DWI-DWM lesion was an independent predictor of futile recanalization (OR 13.97; 95% CI 1.32-147.73; p = 0.028). Conclusion: Patients with large preintervention DWI-DWM lesions may be poor candidates for endovascular therapy.
      Intervent Neurol 2014;3:48-55
  • Endovascular Treatment of Proximal Aortic Arch Lesions through a
           Retrograde Approach
    • Abstract: Tandem atherosclerotic lesions of the carotid bifurcation and the ipsilateral proximal common carotid artery (CCA) or innominate arteries (IA) can be challenging to treat. A surgical approach may treat the lesion at the carotid bifurcation, but proximal CCA or IA lesions require a major surgical exposure. An endovascular approach is challenging as well since anatomic variations, such as a type III aortic arch, can render navigation very difficult. We report our experience in the hybrid surgical and endovascular treatment of complex proximal CCA and IA lesions. Eleven patients who underwent hybrid procedures with surgical exposure (with or without endarterectomy) of the carotid artery and retrograde endovascular intervention of a proximal lesion were included in the study. The mean percentage of stenosis was 81%. Seven patients underwent a carotid endarterectomy (CEA), and 4 patients underwent only a surgical cutdown for retrograde endovascular access of the IA or left CCA. All procedures were technically successful. Eight patients had no symptoms within 30 days of the procedure. The hybrid retrograde endovascular approach through carotid exposure with or without CEA appears to be effective and safe in selected patients who have a high-risk complex anatomy of tandem lesions.
      Intervent Neurol 2014;3:41-47
  • Endovascular Revascularization for Basilar Artery Occlusion
    • Abstract: Basilar artery occlusion is one of the most devastating neurological conditions known to man. Though rare, patients with clinical syndromes localized to this anatomical region are often referred to acute stroke and endovascular units. Recent studies evaluating the efficacy of endovascular approaches to stroke have focused on anterior circulation syndromes. In this review, we examine the approaches to stroke syndromes due to basilar artery thrombosis. We share the relevant data for intravenous and intra-arterial tissue plasminogen activator as well as mechanical approaches to restoring perfusion in this critical area of the brain.
      Intervent Neurol 2014;3:31-40
  • Pulmonary Arteriovenous Malformation as a Cause of Embolic Stroke: Case
           Report and Review of the Literature
    • Abstract: Background: Pulmonary arteriovenous malformation (PAVM) is an abnormal communication between pulmonary arteries and veins responsible for right-to-left shunting that could induce the development of embolic stroke. Summary: We describe an 82-year-old woman without history of respiratory or neurological diseases, who presented at our observation unit with acute onset of cerebral ischemia. Clinical, laboratory and radiological findings diagnosed a PAVM. Key Messages: Usually, endovascular procedures based on embolization or, alternatively, surgery represent the recommended treatment. However, both hormonal therapy and thrombolytic therapy can be used. In our patient, treatment with warfarin induced a remission of symptoms. This strategy should be tested in larger studies.
      Intervent Neurol 2014;3:27-30
  • Stent Placement for Severe Stenosis of the Left Common Carotid Artery with
           Internal-to-External Carotid Steal
    • Abstract: We report the case of a 64-year-old male with internal carotid artery (ICA)-to-external carotid artery (ECA) steal due to severe stenosis of the common carotid artery (CCA). Left CCA occlusion was initially diagnosed on 3-dimensional time-of-flight magnetic resonance angiography, but digital subtraction angiography revealed severe stenosis of the left CCA and retrograde flow through the left ICA feeding the left ECA. Diverted blood flow from ECA to ICA in cases with occlusion or severe stenosis of the CCA represents a well-known alternative collateral flow pattern called ECA-to-ICA steal. However, collateral flow from ICA to ECA is rarely observed and may be termed ICA-to-ECA steal. We treated CCA stenosis in our patient by carotid artery stenting (CAS) because his CCA stenosis had been gradually progressing since the initial ischaemic attack. Antegrade ICA flow subsequently recovered. To the best of our knowledge, this is the first report of ICA-to-ECA steal normalised by the treatment of CCA stenosis using CAS. © 2014 S. Karger AG, Basel
      Intervent Neurol 2014;3:22-26
  • Hemodynamic Changes and Baroreflex Sensitivity Associated with Carotid
           Endarterectomy and Carotid Artery Stenting
    • Abstract: Atherosclerotic carotid lesion is a major cause of stroke which accounts for up to 20% of ischemic stroke. Aggressive treatment of carotid stenosis may prevent stroke. Currently, carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the first-line treatments for severe carotid stenosis. CEA is superior to medical therapy in preventing stroke and cardiovascular death. CAS has emerged as an alternative to CEA in recent years due to its less invasive nature. However, both CEA and CAS may be associated with adverse hemodynamic changes as well as a variation of carotid baroreflex sensitivity. There is no consensus on which of these two methods is more advantageous concerning the procedure-related hemodynamic changes. This article reviews the hemodynamic changes and baroreflex sensitivity after CEA and CAS. © 2014 S. Karger AG, Basel
      Intervent Neurol 2014;3:13-21
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