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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]
  • Ipsilateral Infarct in Newly Diagnosed Cervical Internal Carotid Artery
           Atherosclerotic Occlusion
    • Abstract: Objective: We aimed to determine factors associated with recent infarct (RI) in patients with newly identified atherosclerotic cervical internal carotid artery occlusion (CICAO). Methods: This was a retrospective review of consecutive patients who underwent cervical CT angiography from 2002 to 2006 at a single tertiary center. RI was defined by positive diffusion-weighted imaging/apparent diffusion coefficient magnetic resonance imaging (MRI) in the correspondent CICAO territory. Subjects were dichotomized into those with a RI versus patients with no RI (No-RI). Results: Of 2,459 patients with cervical CT angiograms in the study period, 108 (4.4%) had complete medical records and brain MRI and were included. The mean age was 64 ± 13 years, 58% were men, and 62 (57%) had a RI. The demographics of the RI and No-RI patients were comparable, with the exception that those with RI had a lower frequency of coronary artery disease (CAD, 13 vs. 54%; p < 0.01) and dyslipidemia (38 vs. 69%; p < 0.01). The use of antiplatelets was not statistically different between the groups (56 vs. 71%; p = 0.1). Subjects with RI were less likely on statins (21 vs. 56%; p < 0.01) and antihypertensives (9 vs. 71%; p < 0.01). Multivariate regression revealed that CAD, the use of statins, and the use of antihypertensives were associated with No-RI CICAO presentation. Conclusion: The use of statins and antihypertensives is associated with a decreased risk of RI atherosclerotic CICAO.
      Intervent Neurol 2014;3:142-148
  • Coil Embolization of Wide-Neck Bifurcation Aneurysms Using a
           Single-Balloon Microcatheter
    • Abstract: Background: Coil embolization of wide-neck cerebral aneurysms frequently requires stent or balloon assistance. Such approaches to coil embolization increase the procedural complexity, adding risk and cost. Objective: To describe a series of coil embolization procedures performed using a single-balloon microcatheter to treat wide-neck aneurysms and establish the safety, feasibility and efficacy of this technique. Methods: A retrospective review was performed to identify cases in which the Ascent balloon (Codman Neurovascular, Raynham, Mass., USA) was used as a single-balloon microcatheter for aneurysm coil embolization at two institutions. Clinical, demographic and angiographic data were obtained, and aneurysm volumes as well as packing densities (PD) were calculated. Results: Eight cerebral aneurysms were treated using this technique. Six of these were unruptured. The aneurysms had an average neck diameter of 3.7 mm, and the maximum dimension ranged from 5 to 11 mm, with a mean of 7.5 mm. The mean aspect ratio was 2.07. The mean volume of the aneurysms was 180.38 mm3. The average PD achieved in these 8 aneurysms was 41.79%. Complete occlusion with coil embolization [Raymond-Roy Occlusion Classification (RROC) 1] was achieved in all cases except one, where a small residual was left deliberately and the occlusion grade was RROC 2. There were no intraprocedural complications. Conclusion: This initial experience demonstrates the feasibility and immediate outcomes of a single-balloon microcatheter technique in coil embolization of wide-neck cerebral aneurysms. This technique may be used to achieve a high PD, comparable to that obtained with stent-assisted coiling or coiling alone, while avoiding permanent stent placement and potentially reducing thromboembolic complications.
      Intervent Neurol 2014;3:135-141
  • Comparison of Intraoperative Indocyanine Green Angiography and Digital
           Subtraction Angiography for Clipping of Intracranial Aneurysms
    • Abstract: Background: Residual aneurysm after microsurgical clipping carries a risk of aneurysm growth and rupture. Digital subtraction angiography (DSA) remains the standard to determine the adequacy of clipping. Intraoperative indocyanine green (ICG) angiography is increasingly utilized to confirm optimal clip positioning across the neck and to evaluate the adjacent vasculature. Objective: We evaluated the correlation between ICG and DSA in clipped intracranial aneurysms. Methods: A retrospective study of patients who underwent craniotomy and microsurgical clipping of intracranial aneurysms with ICG for 2 years. Patient characteristics, presentation details, operative reports, and pre- and postclipping angiographic images were reviewed to determine the adequacy of the clipping. Results: Forty-seven patients underwent clipping with ICG and postoperative DSA: 57 aneurysms were clipped; 23 patients (48.9%) presented with subarachnoid hemorrhage. Nine aneurysms demonstrated a residual on DSA not identified on ICG (residual sizes ranged from 0.5 to 4.3 mm; average size: 1.8 mm). Postoperative DSA demonstrated no branch occlusions. Conclusion: Intraoperative ICG is useful in the clipping of intracranial aneurysms to ensure a gross patency of branch vessels; however, the presence of residual aneurysms and subtle changes in flow in branch vessels is best seen by DSA. This has important clinical implications with regard to follow-up imaging and surgical/endovascular management.
      Intervent Neurol 2014;3:129-134
  • Spontaneous Thrombosis of a Ruptured Brain Arteriovenous Malformation: The
           Argument for Early Conservative Management
    • Abstract: Generally, definitive treatment of brain arteriovenous malformations (BAVM) presenting with hemorrhage is recommended to prevent recurrent hemorrhage. The risk of craniotomy and resection of BAVM has been well described using the Spetzler-Martin grading scale; however, the optimal timing for the definitive treatment of ruptured BAVM remains unclear. We report an interesting case of spontaneous BAVM thrombosis in which the patient presented with right occipital intracerebral hemorrhage caused by ruptured right occipital micro-BAVM. A preoperative angiogram 4 months later demonstrated spontaneous thrombosis of the AVM. Despite the risk of re-bleeding, the decision to defer treatment in the acute stage of illness in this case was based on the absence of high-risk angioarchitectural features in the arteriovenous malformations (AVM). It is important to emphasize the potential benefits of early conservative management, particularly in patients with low-risk angiographic features. We also review the literature of spontaneous BAVM thrombosis and discuss the potential benefit of early conservative management.
      Intervent Neurol 2014;3:122-128
  • Endovascular Treatment for Acute Ischemic Stroke: Considerations from
           Recent Randomized Trials
    • Abstract: Background: Despite increasing use of intravenous recombinant tissue plasminogen activator therapy, the large number of patients ineligible for treatment or for whom treatment is ineffective has become problematic. Summary: The number of endovascular treatments for acute ischemic stroke is increasing each year. This treatment provides higher recanalization rates for occluded vessels but may lead to hemorrhagic complications such as subarachnoid hemorrhage. Results were announced for three randomized controlled trials in 2013, with all failing to show the superiority of endovascular treatment. These results have had a major negative impact, but a new randomized controlled trial, the Multicenter Randomized CLinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN), showed that acute endovascular treatment was superior to standard medical treatment in terms of clinical outcomes. With this positive result, interim analyses from other randomized trials appear likely to show the effectiveness of endovascular treatment. Key Message: Clinical evidence of acute stroke intervention using mechanical devices might be established in the near future.
      Intervent Neurol 2014;3:115-121
  • Periprocedural Cost-Effectiveness Analysis of Mechanical Thrombectomy for
           Acute Ischemic Stroke in the Stent Retriever Era
    • Abstract: Background: Early reperfusion is critical for favorable outcomes in acute ischemic stroke (AIS). Stent retrievers lead to faster and more complete reperfusion than previous technologies. Our aim is to compare the cost-effectiveness of stent retrievers to the previous mechanical thrombectomy devices. Methods: Retrospective review of endovascularly treated large-vessel AIS. Data from all consecutive patients who underwent thrombectomy from January 2012 through November 2012 were collected. Baseline characteristics, the total procedural cost, the rates of successful recanalization [modified thrombolysis in cerebral ischemia (mTICI) scores of 2b or 3], and the length of stay at the hospital were compared between the stent retriever (SR) and the non-stent retriever (NSR) groups. Results: After excluding the patients who underwent concomitant extracranial stenting (n = 22) or received intra-arterial tissue plasminogen activator only (n = 6), the entire cohort included 150 patients. The cost of the reperfusion procedure was significantly higher in the SR compared to the NSR group (USD 13,419 vs. 9,308, p
  • Thrombolysis in Chinese Ischemic Stroke Patients with Renal Dysfunction
    • Abstract: Background: Current data concerning the relationship between renal function and clinical outcome among stroke patients treated with intravenous thrombolytic therapy are conflicting. Our aim is to analyze whether the clinical outcome of Chinese ischemic stroke patients treated with thrombolytic therapy is affected by the presence of renal dysfunction. Methods: Chinese patients who received intravenous thrombolytic therapy for acute ischemic stroke were recruited. Renal dysfunction was defined as an estimated glomerular filtration rate (eGFR)
  • 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
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