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Journal Cover Interventional Neurology
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   ISSN (Print) 1664-9737 - ISSN (Online) 1664-5545
   Published by Karger Homepage  [105 journals]
  • Rescue Treatment with Pipeline Embolization for Postsurgical Clipping
           Recurrences of Anterior Communicating Artery Region Aneurysms
    • Abstract: Background: Postsurgical clipping aneurysm recurrences or residuals can be difficult to manage with either traditional open microsurgical approaches or endosaccular coiling. Endoluminal parent vessel reconstruction with flow diversion may be an ideal method for treating these recurrences by avoiding reoperative surgery or intraprocedural aneurysm rupture with aneurysm access. Method: We retrospectively reviewed a single-center aneurysm database identifying all anterior communicating artery (ACom) region aneurysms with recurrences after microsurgical clipping. Cases subsequently treated with Pipeline embolization device (PED) were identified for analysis. Results: Nine PED neurointerventions were performed for the treatment of 6 ACom region recurrent aneurysms after surgical clipping (ACom, n = 4 and A1-A2 junction, n = 2). Of the 6 aneurysms treated, 4 were previously ruptured. Mean patient age was 59.5 ± 6.9 years (range 50-67 years). Mean aneurysm size was 5.1 ± 2.2 mm (range 3-9 mm). Mean fluoroscopy time was 44.1 ± 12.4 min. A single PED, deployed from ipsilateral A2 to ipsilateral A1, was used in 6 cases. No instances of periprocedural complications were encountered. Angiographic follow-up was available in all aneurysms; 5 of these 6 (83%) demonstrated complete aneurysm occlusion. Conclusion: Flow diversion with PED can be a safe and efficacious treatment approach for recurrent ACom region aneurysms after surgical clipping.
      Intervent Neurol 2017;6:135-146
  • Anterior Communicating Artery Aneurysm Treatment with the Pipeline
           Embolization Device: A Single-Center Experience with Long-Term Follow-Up
    • Abstract: Introduction: The pipeline embolization device (PED) is increasingly used in the endovascular management of cerebral aneurysms. Longitudinal data regarding safety and benefit of the PED in anterior communicating (ACOM) artery aneurysms are limited and particularly lacking in residual ACOM artery aneurysms. We report the use of the PED in 3 patients with ACOM artery aneurysms who were previously coiled. Methods: Three patients with ACOM artery aneurysms, all previously treated with coiling and with recurrence of the aneurysm neck, were treated with the PED. All obtained follow-up diagnostic cerebral angiograms at either 3 or 6 months. Results: Mean age of patients was 59 years. All patients received cerebral angiograms at a minimum of 3 months after treatment with the PED. Follow-up angiography was performed up to a mean of 10 months at which time point all cases demonstrated complete aneurysm occlusion, without any stenosis in the parent artery. Conclusion: The PED can be safely used for the treatment of ACOM artery aneurysms. Complete aneurysm obliteration can be achieved in cases refractory to endovascular coiling. These findings warrant replication in a larger data set.
      Intervent Neurol 2017;6:126-134
  • Mechanical Thrombectomy for M2 Occlusions: A Single-Centre Experience
    • Abstract: Background: The recent success of several mechanical thrombectomy trials has resulted in a significant change in the management of patients presenting with stroke. However, questions still remain as to whether certain groups will benefit from mechanical thrombectomy. In particular, it is still uncertain whether mechanical thrombectomy should be performed in the M2 branches and, more generally, in the distal vasculature. Methods: We retrospectively analysed our prospectively maintained database of all patients undergoing mechanical thrombectomy between January 2008 and August 2016. We collected demographic, radiological, procedural and outcome data. Results: We identified 106 patients that met our inclusion criteria. The mean age of the patients was 68 ± 13.8 years, and there were 58 (54.7%) male patients. Associated medical conditions were common with hypertension seen in 71% of the patients. The average Alberta Stroke Program Early CT (ASPECT) score on admission was 8.5 ± 1.7. The mean National Institutes of Health Stroke Scale score was 11.8 ± 7.02. The mean duration of the procedure was 103 ± 3.4 min, and the average number of thrombectomy attempts required was 1.8 (range 1-8). Angiographically, Thrombolysis in Cerebral Infarction Scale (TICI) ≥2b was obtained in 90.5% of the patients. Five patients (4.7%) had symptomatic intracranial haemorrhage on follow-up. At 90-day follow-up, 54.6% of the patients had a modified Rankin Scale (mRS) score 0-2, and 71.5% had an mRS score ≤3. There were 15 deaths at 90 days (14.1%). Conclusion: Mechanical thrombectomy in patients with solitary M2 clots is technically possible and carries a high degree of success with a good safety profile. Patients with confirmed M2 occlusion should be considered for mechanical thrombectomy.
      Intervent Neurol 2017;6:117-125
  • Radiation Exposure during Neurointerventional Procedures in Modern Biplane
           Angiographic Systems: A Single-Site Experience
    • Abstract: Background and Purpose: Per the ALARA principle, reducing the dose delivered to both patients and staff must be a priority for endovascular therapists, who should monitor their own practice. We evaluated patient exposure to radiation during common neurointerventions performed with a recent flat-panel detector angiographic system and compared our results with those of recently published studies. Methods: All consecutive patients who underwent a diagnostic cerebral angiography or intervention on 2 modern flat-panel detector angiographic biplane systems (Innova IGS 630, GE Healthcare, Chalfont St Giles, UK) from February to November 2015 were retrospectively analyzed. Dose-area product (DAP), cumulative air kerma (CAK) per plane, fluoroscopy time (FT), and total number of digital subtraction angiography (DSA) frames were collected, reported as median (interquartile range), and compared with the previously published literature. Results: A total of 755 consecutive cases were assessed in our institution during the study period, including 398 diagnostic cerebral angiographies and 357 interventions. The DAP (Gy × cm2), fontal and lateral CAK (Gy), FT (min), and total number of DSA frames were as follows: 43 (33-60), 0.26 (0.19-0.33), 0.09 (0.07-0.13), 5.6 (4.2-7.5), and 245 (193-314) for diagnostic cerebral angiographies, and 66 (41-110), 0.46 (0.25-0.80), 0.18 (0.10-0.30), 18.3 (9.1-30.2), and 281 (184-427) for interventions. Conclusion: Our diagnostic cerebral angiography group had a lower median and was in the 75th percentile of DAP and FT when compared with the published literature. For interventions, both DAP and number of DSA frames were significantly lower than the values reported in the literature, despite a higher FT. Subgroup analysis by procedure type also revealed a lower or comparable DAP.
      Intervent Neurol 2017;6:105-116
  • Utilization of a Novel, Multi-Durometer Intracranial Distal Access
           Catheter: Nuances and Experience in 110 Consecutive Cases of Aneurysm Flow
    • Abstract: Background: Coaxial catheter support systems provide a safe and stable foundation in endovascular treatment of intracranial aneurysms. Increasingly, robust distal intracranial support is sought during complex neurointerventions. The AXS Catalyst 5 distal access catheter (Cat5) is a new intracranial catheter designed for improved trackability and stability. We report the first experience using Cat5 for aneurysm treatment by flow diversion. Methods: A single-center aneurysm database was reviewed for cases of aneurysm treatment with the Pipeline embolization device (PED) that utilized Cat5. Data were collected for patient demographics, aneurysm characteristics, procedural details, catheter positions, vessel tortuosity, and catheter related complications. Results: One hundred and ten cases of aneurysm flow diversion were successfully performed using Cat5. Patient age ranged from 21 to 86 years (mean 57 ± 12.5 years) with 84% women. Aneurysm size ranged from 2 to 28 mm (mean 5.7 ± 5.0 mm), with 97% in the anterior circulation. Twenty-four aneurysms (22%) were located beyond the ICA termination. Significant cervical carotid tortuosity was present in 26% of cases, and moderate to severe cavernous tortuosity (cavernous grade ≥2) in 45% of cases. Cat5 was tracked to the intended distal position in all cases with 100% technical success of PED implantation. No iatrogenic catheter-related vessel injury occurred, and major neurological morbidity occurred in 1 patient (1%). Summary: The Cat5 is a novel, multi-durometer cranial distal access catheter designed for use in tri-axial systems. We have demonstrated the utility of Cat5 in 110 successful cases of flow diversion with a wide range of complexity. This catheter is a new tool in the neurointerventionalist's armamentarium to achieve robust and atraumatic distal access.
      Intervent Neurol 2017;6:90-104
  • Endovascular Embolization of Intracranial Infectious Aneurysms in Patients
           Undergoing Open Heart Surgery Using n-Butyl Cyanoacrylate
    • Abstract: Introduction: Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce. Methods: Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015. Results: Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization. Conclusions: Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.
      Intervent Neurol 2017;6:82-89
  • Embolization of Sacral Dural Arteriovenous Fistulas: A Case Series and
           Literature Review
    • Abstract: The authors report 2 cases of sacral dural arteriovenous fistula (AVF) presenting with gradual neurologic decline characterized by progressive lower extremity weakness and bowel and bladder incontinence. Spinal angiography demonstrated a sacral dural AVF with perimedullary vein engorgement and drainage extending to the level of the cervical spine in both cases. The fistulas were completely obliterated with n-BCA (n-butyl cyanoacrylate) embolic agent in one case, and with ethylene vinyl alcohol (Onyx) in the second, resulting in improvement of the symptoms in both patients. The unique features of this case report include the rare location of the fistula's origin, the necessity for complete spinal angiography, and the use of intraoperative monitoring in one case to guide embolization treatment.
      Intervent Neurol 2017;6:73-81
  • Mechanical Thrombectomy in Pregnancy: Report of 2 Cases and Review of the
    • Abstract: Background: Mechanical thrombectomy has recently proved extremely effective in improving the outcome of patients with large vessel occlusion. Despite this, questions still remain over certain cohorts of patients that were excluded from the large randomised controlled trials. One such cohort includes pregnant patients. Although thromboembolic stroke is uncommon in pregnancy, the outcome from this pathology can be devastating. Summary: We present 2 cases of mechanical thrombectomy in pregnancy both of which underwent successful flow restoration without complications. We discuss the incidence of stroke in pregnancy, potential pitfalls of imaging, radiation protection issues, and the role of thrombolysis as well as the available literature on mechanical thrombectomy in this cohort. Key Message: Thrombectomy in pregnancy can be performed safely with no significant changes required to the procedure itself. Radiation exposure during the procedure should be minimised and shielding used to prevent scatter radiation to the fetus; however, given the potential risks of thrombolysis in this cohort of patients, mechanical thrombectomy should be considered in all stages of pregnancy.
      Intervent Neurol 2017;6:49-56
  • Simultaneous Kissing Stenting: A Valuable Technique for Reconstructing the
           Stenotic Initial Segment of the Right Subclavian Artery
    • Abstract: Atherosclerotic stenosis or occlusion often involves the subclavian artery. For lesions that are close to the orifice of the right subclavian artery, stenting of the right subclavian artery itself blocks the pathway from the innominate artery to the right carotid artery and causes problems in patients with multiple angiostenosis, especially involving the right carotid system. In this study, we report 2 cases using simultaneous kissing stenting (SKS) of the right subclavian artery and the right carotid artery to relieve right subclavian stenosis and maintain right carotid system patency. Standard stenting methods were used to perform SKS. Two self-expanding stents were implanted simultaneously into the initial segment of the right subclavian artery and the right carotid artery, forming a “Y” shape, with the overlap of the proximal segments in the innominate artery ≥5 mm. After SKS, the stenosed right subclavian artery was dilated, and the patency of the right carotid system was maintained. The symptoms of patients were relieved and the stents were intact at several months of follow-up. In conclusion, SKS of the right subclavian artery and the right carotid artery might be a safe and effective procedure when the stenotic or occlusive lesion in the initial segment of the right subclavian artery is close to the orifice, and lesions (or potential ones) exist in the right carotid system.
      Intervent Neurol 2017;6:65-72
  • Risk of Intracranial Hemorrhage after Endovascular Treatment for Acute
           Ischemic Stroke: Systematic Review and Meta-Analysis
    • Abstract: Background: Intracranial hemorrhage is a major complication of endovascular treatment in patients with acute ischemic stroke. Controlled clinical trials reported varied incidences of intracranial hemorrhage after endovascular treatment. This meta-analysis aimed to estimate whether endovascular treatment, compared with medical treatment, increases the risk of intracranial hemorrhage in patients with acute ischemic stroke. Methods: The current publications on endovascular treatment for acute ischemic stroke were systematically reviewed. Rates of intracranial hemorrhage after endovascular treatment for acute ischemic stroke reported in controlled clinical trials were pooled and analyzed. Random and fixed-effect models were used to pool the outcomes. For analyzing their individual risks, intracranial hemorrhages after endovascular treatment were classified as symptomatic and asymptomatic. Results: Eleven studies involving 1,499 patients with endovascular treatment and 1,320 patients with medical treatment were included. After pooling the data, the risk of any intracranial hemorrhage was significantly higher in patients with endovascular treatment than in patients with medical treatment (35.0 vs. 19.0%, OR = 2.55, 95% CI: 1.64-3.97, p < 0.00001). The risk of asymptomatic intracranial hemorrhage was also significantly higher in patients with endovascular treatment than in those with medical treatment (28 vs. 12%, OR = 3.16, 95% CI: 1.62-6.16, p < 0.001). However, the risks of symptomatic intracranial hemorrhage were similar in patients with endovascular treatment and in those with medical treatment (5.6 vs. 5.2%, OR = 1.09, 95% CI: 0.79-1.50, p = 0.61). Conclusion: Although the risk of any intracranial hemorrhage may increase after endovascular treatment, the risk of symptomatic intracranial hemorrhage may remain similar as compared with medical treatment.
      Intervent Neurol 2017;6:57-64
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