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Interventional Neurology    Follow    
  Full-text available via subscription Subscription journal
     ISSN (Print) 1664-9737 - ISSN (Online) 1664-5545
     Published by Karger Homepage  [103 journals]
  • 6th Annual Meeting of the Society of Vascular and Interventional
           Neurology, October 26-27, 2013, Houston, Texas: Abstracts
    • Abstract:
      Intervent Neurol 2013;2:57-96
       
  • Predictors and Outcomes of Suspected Heparin-Induced Thrombocytopenia in
           Subarachnoid Hemorrhage Patients
    • Abstract: Background: Heparin-induced thrombocytopenia (HIT) is a dreaded complication of heparin-related products and correlates with a worse outcome in aneurysmal subarachnoid hemorrhage (SAH) patients. Objective: To study the risk factors and outcomes of SAH patients suspected of having HIT, confirmed as present or absent by the platelet factor 4 (PF4) antibody test. Methods: All patients with presumed aneurysmal, nontraumatic SAH and having undergone a PF4 test were identified through our research patient database. Charts, laboratory values and images were analyzed retrospectively. Results: We identified 166 patients with SAH who were tested for HIT; 42 patients (25%) had a positive antibody test. There was no difference in platelet profiles or mean platelet nadirs of HIT+ and HIT- patients (147 ± 93 vs. 153 ± 86 ×109/l, respectively). Univariate analysis identified gender, magnesium prophylaxis, Fisher group 3, clipping versus coiling, presence of angiographic vasospasm, number of vasospasm treatments, and day of HIT testing as potential risk factors associated with HIT. A multivariate analysis indicated that female gender (OR 8.2, 95% CI 2.0-33.2), greater number of vasospasm treatments (OR 1.5, 95% CI 1.2-2.0), later day of HIT testing (OR 1.2, 95% CI 1.1-1.3), and clipping (OR 5.0, 95% CI 1.42-10.0) were independently associated with HIT positivity. HIT+ patients showed more infarcts on CT, longer ICU and hospital stays and worse modified Rankin Scale scores on discharge. Conclusion: The presence of HIT in SAH has adverse consequences and is more likely in female patients who have undergone aneurysm clipping and require multiple endovascular vasospasm treatments. © 2014 S. Karger AG, Basel
      Intervent Neurol 2013;2:160-168
       
  • Computed Tomography Angiography in the Stroke Outcomes and Neuroimaging of
           Intracranial Atherosclerosis (SONIA) Study
    • Abstract: Background: The Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) study validated noninvasive imaging tests of intracranial atherosclerosis against catheter angiography in a prospective, blinded, multicenter setting. Critical evaluation of transcranial Doppler (TCD) and magnetic resonance angiography in the SONIA study standardized their performance and interpretation. We performed a similar analysis of computed tomography angiography (CTA) for the detection of intracranial stenosis. Methods: Multicenter standardization of image acquisition and blinded, central interpretation of CTA performance were conducted in concert with the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial. Measurements of the intracranial arterial diameter were obtained to derive stenosis values. Correlation with catheter angiography was used to assess CTA performance characteristics. Results: CTA measurements of intracranial stenosis were obtained in 120 vessel segments, with angiographic correlation in 52. CTA was performed as a noninvasive study prior to conventional angiography. CTA stenoses of 50-99% or a flow gap were identified in 15 of 52 vessel segments, stenoses of
       
  • Intra-Arterial Treatment of Acute Ischemic Stroke: Better Outcome with
           Stent Retrievers
    • Abstract: Background: Intra-arterial treatment is increasingly used in acute ischemic stroke. Recently, new devices have become available, aiming at better recanalization rates and outcome. We present a series of patients with acute stroke of the anterior circulation treated with intra-arterial therapy using intra-arterial thrombolysis and different types of mechanical devices. Methods: We prospectively gathered clinical and radiological data of all patients with acute anterior stroke who were treated with intra-arterial therapy in a Dutch teaching hospital between 2009 and 2011. Patients were grouped according to the intra-arterial treatment strategy and analyzed for poor outcome (modified Rankin Scale score >2 or death), complications and recanalization rate with the Poisson regression. Results: Eighty-four patients were treated with intra-arterial therapy, 13 with intra-arterial thrombolysis only (ND group), 22 with a Merci device (MERCI group) and 49 with a stent retriever (SR group). Overall, 52 patients (62%) had poor outcome of whom 17 (20%) died. There was a trend towards poorer outcome in the ND group (adjusted RR 1.18; 95% CI 0.74-1.88) and the MERCI group (adjusted RR 1.17; 95% CI 0.79-1.74) compared with the SR group. Furthermore, failed recanalization occurred more often in the ND group (adjusted RR 2.59; 95% CI 1.50-4.49) and MERCI group (adjusted RR 2.32; 95% CI 1.33-4.05) compared with the SR group. Conclusion: We found higher recanalization rates with SRs. However, this resulted only in a trend towards better clinical outcome. © 2014 S. Karger AG, Basel
      Intervent Neurol 2013;2:144-152
       
  • Idiopathic Intracranial Hypertension: A Systematic Analysis of Transverse
           Sinus Stenting
    • Abstract: Background: Idiopathic intracranial hypertension (IIH) is a disorder characterized by signs and symptoms of increased intracranial pressure without structural cause seen on conventional imaging. Hallmark treatment after failed medical management has been CSF shunting or optic nerve fenestration with the objective of preserving vision. Recently, there have been multiple case reports and case series on dural sinus stenting for this disorder. Objective: We aim to review all published cases and case series of dural sinus stenting for IIH, with analysis of patients' presenting symptoms, objective findings (CSF pressures, papilledema, pressure gradients across dural sinuses), follow-up of objective findings, and complications. Methods: A Medline search was performed to identify studies meeting prespecified criteria of a case report or case series of patients treated with dural sinus stent placement for IIH. The papers were reviewed and data were extracted. Results: A total of 22 studies were identified, of which 19 studies (including a total of 207 patients) met the criteria and were included in the analysis. Only three major complications related to the procedure were identified. Headaches resolved or improved in 81% of patients. Papilledema improved in 90% of cases (172 of 189 patients). Sinus pressure decreased from an average of 30.3 to 15 mm Hg. Sinus pressure gradient decreased from 18.5 mm Hg (n = 185) to 3.2 mm Hg (n = 172). Stenting had an overall symptom improvement rate of 87%. Conclusion: Although all published case reports and case series are nonrandomized, the low complication and high symptom improvement rate make dural sinus stenting for IIH a potential alternative surgical treatment. Standardized patient selection and randomization trials or registry are warranted. © 2014 S. Karger AG, Basel
      Intervent Neurol 2013;2:132-143
       
  • Carotid Baroreceptor Stimulation: A Potential Solution for Resistant
           Hypertension
    • Abstract: Resistant hypertension indicates that the blood pressure cannot reach the target value despite standard drug treatment, which harbors an increased risk for cardiovascular diseases. The role of the carotid sinus in regulating blood pressure has long been observed; thereby, the idea that treating resistant hypertension by stimulating carotid baroreceptors emerged. Nevertheless, this idea has been abandoned for years due to technical limitations. Recently, with the evolutions in implantable electrical devices, expectations for treating resistant hypertension with baroreceptor stimulation have increased. Positive results from several multicenter clinical trials further captured the researchers' enthusiasm for more effective baroreceptor-stimulating devices. This study reviews the recent progress in baroreceptor stimulation as a treatment alternative for resistant hypertension. © 2014 S. Karger AG, Basel
      Intervent Neurol 2013;2:118-122
       
  • The Future of Ischemic Stroke: Flow from Prehospital Neuroprotection to
           Definitive Reperfusion
    • Abstract: Recent advances in ischemic stroke enable a seamless transition of the patient flow from the prehospital setting to definitive reperfusion, without the arbitrary separation of therapeutic phases of ischemia based on time alone. In 2013, the framework to understand and directly address the pathophysiology of cerebral blood flow that determines the timeline or evolution of ischemia in an individual case is given. This continuum of flow and the homeostasis of brain perfusion balanced by collaterals may be captured with serial imaging. Ongoing imaging core laboratory activities permit large-scale measurement of angiographic and tissue biomarkers of ischemia. Prehospital neuroprotection has become a reality and may be combined with revascularization therapies. Recent studies confirm that image-guided thrombolysis may be achieved without restrictive time windows. Baseline imaging patterns may be used to predict response to therapy and serial imaging may discern recanalization and reperfusion. Advanced techniques, such as arterial spin-labeled MRI, may also report hyperperfusion associated with hemorrhagic transformation. Endovascular therapies, including novel stent retriever devices, may augment revascularization and angiographic core laboratories may define optimal reperfusion. Serial evaluation of collaterals and reperfusion may identify definitive reperfusion linked with good clinical outcome rather than imposing arbitrary definitions of effective recanalization. Reperfusion injury and hemorrhagic transformation of various types may be detailed to explain clinical outcomes. Similar approaches may be used in intracranial atherosclerosis where flow, and not the degree of luminal stenosis, is paramount. Fractional flow may now be measured with computational fluid dynamics to identify high-risk lesions that require revascularization to restore the equilibrium of antegrade and collateral perfusion. Serial perfusion imaging of such cases may also illustrate inadequate cerebral blood volume gradients that may be more informative than blood flow delay alone. In sum, the growing understanding of collateral perfusion throughout all stages of ischemic stroke provides a framework for the future of ischemic stroke. © 2014 S. Karger AG, Basel
      Intervent Neurol 2013;2:105-117
       
  • Stenting and Angioplasty of Small Cerebral Arteries in Symptomatic
           Intracranial Atherosclerotic Disease
    • Abstract: Background: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke with a poor natural history despite medical therapy. Few studies have investigated endovascular therapies for the treatment of symptomatic ICAD in distal intracranial arteries. Here, we present the feasibility and safety of balloon angioplasty with and without stenting in patients with medically refractory small-artery symptomatic ICAD. Methods: Personal logs were reviewed to identify patients who were treated for small-artery ICAD (stenosis >50%) using angioplasty and/or stenting. Small cerebral arteries were defined by a diameter of ≤2 mm or any branch distal to a large intracranial vessel (i.e. distal to the internal carotid artery, M1, A1, or vertebrobasilar trunk). Patient characteristics, clinical manifestations, treatment, hospital course, and follow-up data were collected and analyzed. Results: Ten patients (12 arteries) were treated with either primary balloon angioplasty (58.3%) or angioplasty with stenting (41.6%) with a 100% technical success rate. Mean pretreatment stenosis was 79.9%, while mean posttreatment stenosis was 19.0%. There were no major periprocedural complications, including symptomatic intracranial hemorrhage or mortality; 3 cases were complicated by groin hematoma. Patients were followed for a mean total of 18.6 months with only 1 symptomatic restenosis which was retreated successfully. All patients had good functional outcome with a modified Rankin Scale of either 0 (80%) or 1 (20%) on follow-up. Conclusion: In our case series, treatment of symptomatic small-artery ICAD with angioplasty and/or stenting was safe and effective. These interventions should be considered as an alternative treatment for ICAD patients refractory to medical therapy. © 2014 S. Karger AG, Basel
      Intervent Neurol 2013;2:123-131
       
  • Future Directions for Intra-Arterial Therapy for Acute Ischaemic Stroke:
           Is There Life after Three Negative Randomized Controlled Studies
    • Abstract: Background: The three randomised controlled trials, Interventional Management of Stroke III (IMS3), Mechanical Retrieval and Revascularization of Stroke Clots Using Embolectomy (MR RESCUE) and Synthesis Expanasion: A Randomized Controlled Trial on Intra-Arterial Versus Intravenous Thrombolysis in Acute Ischaemic Stroke (SYNTHESIS EXP) showed no significant difference in clinical outcomes comparing intra-arterial (IA) therapy with intravenous thrombolysis. This article will explore the reasons for failure to show superiority of IA therapy. Summary: There are many reasons for the disappointing results of the three randomised controlled trials. Opposing views on IA therapy exist. Critics argue that only a small percentage of patients will be eligible for IA therapy and that it will never be cost-effective. Additionally, current trials have failed to address superior recanalization rates of new generation devices and lack of patient selection by advanced imaging. Time-to-treatment is longer in these randomised controlled trials and stroke outcomes were worse than anticipated. The current randomised controlled trials also took long periods to complete. There is emerging evidence that general anesthetic negatively influences outcome. Next generation trials will attempt to address these issues. Key Messages: There are disparate explanations for the disappointing results from the three IA therapy randomized controlled studies. Poor recanalisation rates with first generation endovascular devices, lack of advanced neuroimaging to aid in patient selection, lack of data surrounding the use of general anaesthesia, and prolonged time-to-treatment are potential contributors to negative results. The new generation of trials has the potential of addressing these pressing issues. © 2014 S. Karger AG, Basel
      Intervent Neurol 2013;2:97-104
       
  • Mechanical Thrombectomy Trials with the Solitaire™ FR Device: A
           Global Perspective
    • Abstract: Intervent Neurol 2013;2:52-56
       
 
 
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