Publications by authors named "Beverly Aagaard-Kienitz"

31 Publications

Low profile sheaths in pediatric neurointervention: a multicenter experience.

J Neurointerv Surg 2021 Oct 8. Epub 2021 Oct 8.

Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA.

Background: Pediatric neurointervention is challenged by the appropriateness of adult catheters and devices. This multicenter report on the smallest groin access sheaths offers technical notes and clinical outcomes in the pediatric neurointerventional population.

Methods: All pediatric neurointerventional cases from 2019 to 2021 were reviewed for use of a 3.3F Pediavascular or a 4F Merit Prelude Ideal low profile sheath. Hospital records were reviewed for complications and technical notes and compared with arterial groin access with the 4F Terumo Pinnacle in infants less than 1 year old, before the low profile sheaths at one author's institution were introduced.

Results: From January 1, 2019 to March 31, 2021 there were 347 procedures performed at Boston Children's Hospital and University of Wisconsin. Forty-four procedures in 26 patients were identified in which a 3.3F (38 cases, 20 patients) or 4F (6 cases, 6 patients) sheath was used. The average age was 2.2 years (1.5 days to 18 years). Retinoblastoma intra-arterial chemotherapy infusion (18 of 44) was the most common indication. The remaining procedures comprised vein of Galen embolization (12), diagnostic cerebral angiography (13), and one preoperative tumor embolization. Morbidity included a groin hematoma and decreased pulses (4.5%). No major groin complications occurred. There was no statistically significant difference compared with the historical cohort (132 procedures), which had seven instances of decreased pulses (5.3%, p>0.05).

Conclusion: The 3.3F Pediavascular and 4F Merit Prelude Ideal sheaths are easily incorporated into the pediatric neurointerventionalist's armamentarium for infants and readily accommodate various microcatheters for distal embolization and catheterization.
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http://dx.doi.org/10.1136/neurintsurg-2021-017936DOI Listing
October 2021

Achievable aspiration flow rates with large balloon guide catheters during carotid artery stenting.

CVIR Endovasc 2020 Sep 10;3(1):65. Epub 2020 Sep 10.

Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.

Background: Emergency carotid artery stenting (CAS) is a frequent endovascular procedure, especially in combination with intracranial thrombectomy. Balloon guide catheters are frequently used in these procedures. Our aim was to determine if mechanical aspiration through the working lumen of a balloon occlusion catheter during the steps of a carotid stenting procedure achieve flow rates that may lead to internal carotid artery (ICA) flow reversal which consecutively may prevent distal embolism.

Methods: Aspiration experiments were conducted using a commercially available aspiration pump. Aspiration flow rates/min with 6 different types of carotid stents inserted into a balloon guide catheter were measured. Measurements were repeated three times with increasing pressure in the phantom. To determine if the achieved aspiration flow rates were similar to physiologic values, flow rates in the ICA and external carotid artery (ECA) in 10 healthy volunteers were measured using 4D-flow MRI.

Results: Aspiration flow rates ranged from 25 to 82 mL/min depending on the stent model. The pressure in the phantom had a significant influence on the aspiration volume. Mean blood flow volumes in volunteers were 210 mL/min in the ICA and 101 mL/min in the ECA.

Conclusions: Based on the results of this study, flow reversal in the ICA during common carotid artery occlusion is most likely achieved with the smallest diameter stent sheath and the stent model with the shortest outer stent sheath maximum diameter. This implies that embolic protection during emergency CAS through aspiration is most effective with these models.
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http://dx.doi.org/10.1186/s42155-020-00134-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483693PMC
September 2020

Difference in imaging biomarkers between transient and permanent neurological deficits after endovascular treatment of cerebrovascular aneurysms.

J Neurosurg 2020 06 19;134(6):1861-1870. Epub 2020 Jun 19.

Departments of1Neurological Surgery and.

Objective: The literature suggests that blood-brain barrier disruption (BBBD) plays a significant role in the development of neurological events in patients with diffusion-weighted imaging (DWI) that is negative for lesions. In this prospective, single-center cohort study, the authors compared the imaging characteristics of patients suffering transient neurological events (TNEs) with those in patients suffering permanent neurological events (PNEs) after having undergone elective embolization of unruptured intracranial aneurysms.

Methods: This prospective cohort study was conducted between July 2016 and June 2019. Inclusion criteria were adults undergoing elective neuroendovascular procedures and the absence of contraindications to MRI. All subjects underwent brain MRI including postcontrast FLAIR (pcFLAIR) sequences for evaluation of BBBD within 24 hours postprocedure.

Results: In total, 128 patients harboring 133 unruptured aneurysms were enrolled, 109 of whom (85.2%) showed some degree of BBBD on pcFLAIR MRI and 50 of whom (39.1%) suffered an ischemic insult per DWI. In total, 23 patients (18%) suffered neurological complications, 16 of which (12.5%) were TNEs and 7 of which (5.5%) were PNEs. The median extent of BBBD was focal in asymptomatic patients as compared to hemispheric and lobar in the TNE and PNE groups, respectively (p < 0.001). The American Society of Anesthesiologists physical status classification predicted the extent of BBBD (p = 0.046). Lesions on DWI were noted in 34 asymptomatic patients (32.4%) compared to 9 patients (56.3%) with TNEs and all 7 patients (100%) with PNEs (p < 0.001). The median number of DWI lesions was 0 (range 0-18 lesions) in the asymptomatic group compared to 1.5 (range 0-8 lesions) and 8 (range 1-13 lesions) in the TNE and PNE groups, respectively (p < 0.001). Smoking (p = 0.008), older age (p = 0.002), and longer surgery (p = 0.006) were positively associated with the number of lesions on DWI. On multivariate analysis, intraarterial verapamil (p = 0.02, OR 8.01, 95% CI 1.35-47.43) and extent of BBBD (p < 0.001, OR 58.58, 95% CI 9.48-361.84) were positively associated with the development of TNEs, while intravenous infusion of midazolam during surgery (p = 0.02, OR 6.03, 95% CI 1.29-28.20) was negatively associated. An increased number of lesions on DWI was the only significant predictor for the development of PNEs (p < 0.001, OR 49.85, 95% CI 5.56-447.10).

Conclusions: An increasing extent of BBBD was associated with the development of TNEs, whereas an increasing number of lesions on DWI was significantly associated with the development of PNEs. BBBD imaging using pcFLAIR may serve as a valuable biomarker for detecting subtle cerebral ischemia and stratifying the risk for ischemic events.
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http://dx.doi.org/10.3171/2020.4.JNS192718DOI Listing
June 2020

Prospective study on embolization of intracranial aneurysms with the pipeline device: the PREMIER study 1 year results.

J Neurointerv Surg 2020 Jan 15;12(1):62-66. Epub 2019 Jul 15.

New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

Background: Preliminary clinical studies on the safety and efficacy of the pipeline embolization device (PED) for the treatment of small/medium aneurysms have demonstrated high occlusion rates with low complications.

Objective: To evaluate the safety and effectiveness of the PED for treatment of wide necked small and medium intracranial aneurysms.

Methods: PREMIER is a prospective, multicenter, single arm trial. Patients were treated with the PED for unruptured wide necked aneurysms, measuring ≤12 mm along the internal carotid artery or vertebral artery, between July 2014 and November 2015. At 1 year post-procedure, the primary effectiveness endpoint was complete occlusion (Raymond grade 1) without major parent vessel stenosis (≤50%) or retreatment, and the primary safety endpoint was major stroke in the territory supplied by the treated artery or neurologic death.

Results: A total of 141 patients were treated with PEDs (mean age 54.6±11.3 years, 87.9% (124/141) women). Mean aneurysm size was 5.0±1.92 mm, and 84.4% (119/141) measured <7 mm. PED placement was successful in 99.3% (140/141) of patients. Mean number of PEDs implanted per patient was 1.1±0.26; a single PED was used in 92.9% (131/141) of patients. At 1 year, 97.9% (138/141) of patients underwent follow-up angiography with 76.8% (106/138) of patients having met the study's primary effectiveness endpoint. The combined major morbidity and mortality rate was 2.1% (3/140).

Conclusions: Treatment of wide necked small/medium aneurysms with the PED results in high rates of complete occlusion without significant parent vessel stenosis and low rates of permanent neurologic complications.

Trial Registration: NCT02186561.
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http://dx.doi.org/10.1136/neurintsurg-2019-015091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996098PMC
January 2020

Serial Quantitative and Qualitative Measurements of Flow in Vein of Galen Malformations Using 4-Dimensional Flow Magnetic Resonance Imaging (Phase Contrast Vastly undersampled Isotropic PRojection).

World Neurosurg 2019 Jun 5;126:405-412. Epub 2019 Mar 5.

Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA; Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA. Electronic address:

Background: Vein of Galen malformations (VoGMs) induce cerebrovascular dysfunction through arterial steal and venous hypertension resulting, if untreated, in severe neurologic morbidity and mortality. Noninvasive techniques for quantitative, serial evaluation of cerebrovascular hemodynamics in VoGMs are lacking. This proof of concept study using quantitative blood flow measurements from 4-dimensional flow magnetic resonance imaging may be useful as a noninvasive biomarker to guide timing of intervention and assess disease progression and treatment outcomes.

Case Description: Between July 2016 and July 2018, 4 patients harboring VoGMs underwent Phase Contrast Vastly undersampled Isotropic PRojection (PCVIPR) imaging at the University of Wisconsin Hospitals and Clinics. We applied PCVIPR imaging to assess its potential for obtaining anatomic and physiologic flow data before and after surgical embolization of VoGMs. Hemodynamic pressure parameters obtained from PCVIPR imaging were compared with stump pressures recorded in vivo. We found a decrease in mean arterial pressure from 97 mm Hg pretreatment to 65 mm Hg post treatment. These findings corroborate the decrement in venous pressure gradients documented on PCVIPR imaging. For all patients, pressure gradient changes on PCVIPR imaging correlated with in vivo arterial pressures and aided in clinical decision related to cerebrovascular evaluation, treatment planning, and clinical course.

Conclusions: Four-dimensional flow magnetic resonance imaging/PCVIPR imaging has a potential role in determining endovascular embolization and therapeutic outcomes on the basis of objective and reproducible hemodynamic characteristics of the vascular lesion. It represents a novel, noninvasive approach that may guide the extent and timing of therapeutic intervention and treatment of cerebrovascular diseases in pediatric patients.
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http://dx.doi.org/10.1016/j.wneu.2019.02.131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924166PMC
June 2019

Mutations in Chromatin Modifier and Ephrin Signaling Genes in Vein of Galen Malformation.

Neuron 2019 02 18;101(3):429-443.e4. Epub 2018 Dec 18.

Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, and Department of Medicine, Harvard Medical School, Boston, MA, USA.

Normal vascular development includes the formation and specification of arteries, veins, and intervening capillaries. Vein of Galen malformations (VOGMs) are among the most common and severe neonatal brain arterio-venous malformations, shunting arterial blood into the brain's deep venous system through aberrant direct connections. Exome sequencing of 55 VOGM probands, including 52 parent-offspring trios, revealed enrichment of rare damaging de novo mutations in chromatin modifier genes that play essential roles in brain and vascular development. Other VOGM probands harbored rare inherited damaging mutations in Ephrin signaling genes, including a genome-wide significant mutation burden in EPHB4. Inherited mutations showed incomplete penetrance and variable expressivity, with mutation carriers often exhibiting cutaneous vascular abnormalities, suggesting a two-hit mechanism. The identified mutations collectively account for ∼30% of studied VOGM cases. These findings provide insight into disease biology and may have clinical implications for risk assessment.
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http://dx.doi.org/10.1016/j.neuron.2018.11.041DOI Listing
February 2019

The effect of flow diverting stents on in vivo intrasaccular aneurysm pressure.

J Clin Neurosci 2019 Jan 13;59:339-341. Epub 2018 Nov 13.

Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jocn.2018.10.093DOI Listing
January 2019

Increasing Access to High Value Care: Preventing Complications in Common Disorders.

Telemed J E Health 2019 05 10;25(5):423-424. Epub 2018 Aug 10.

1 Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

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http://dx.doi.org/10.1089/tmj.2018.0003DOI Listing
May 2019

Differences in Pressure Within the Sac of Human Ruptured and Nonruptured Cerebral Aneurysms.

Neurosurgery 2019 06;84(6):1261-1268

Department of Neurological Surgery, Neuro Interventional Radiology, University of Wisconsin Medical School, Madison, Wisconsin.

Background: Hemodynamics plays a critical role in the development, growth, and rupture of intracranial aneurysms. This data could be vital in determining individual aneurysm rupture risk and could facilitate our understanding of aneurysms.

Objective: To present the largest prospective cross-sectional cohort study of intrasaccular pressure recordings of ruptured and nonruptured intracranial aneurysms and describe the hemodynamic differences that exist between ruptured and nonruptured aneurysms.

Methods: During endovascular treatment, a standard 1.8-Fr 200 m length microcatheter was navigated into the dome of the aneurysm prior to coil embolization. With the microcatheter centralized within the dome of the aneurysm, an arterial pressure transducer was attached to the proximal end of the microcatheter to measure the stump pressure inside the aneurysm dome.

Results: In 68 aneurysms (28 ruptured, 40 nonruptured), we observed that ruptured cerebral aneurysms had a lower systolic and mean arterial pressure compared to nonruptured cohort (P = .0008). Additionally, the pulse pressures within the dome of ruptured aneurysms were significantly more narrow than that of unruptured aneurysms (P = .0001). These findings suggest that there may be an inherent difference between ruptured and nonruptured aneurysms and such recordings obtained during routine digital subtraction angiography could potentially become a widely applied technique to augment risk stratification of aneurysms.

Conclusion: Our preliminary data present new evidence distinguishing ruptured from unruptured aneurysms that may have a critical role as a predictive parameter to stratify the natural history of nonruptured intracranial aneurysms and as a new avenue for future investigation.
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http://dx.doi.org/10.1093/neuros/nyy182DOI Listing
June 2019

Human genetics and molecular mechanisms of vein of Galen malformation.

J Neurosurg Pediatr 2018 04 19;21(4):367-374. Epub 2018 Jan 19.

1Department of Neurosurgery.

Vein of Galen malformations (VOGMs) are rare developmental cerebrovascular lesions characterized by fistulas between the choroidal circulation and the median prosencephalic vein. Although the treatment of VOGMs has greatly benefited from advances in endovascular therapy, including technical innovation in interventional neuroradiology, many patients are recalcitrant to procedural intervention or lack accessibility to specialized care centers, highlighting the need for improved screening, diagnostics, and therapeutics. A fundamental obstacle to identifying novel targets is the limited understanding of VOGM molecular pathophysiology, including its human genetics, and the lack of an adequate VOGM animal model. Herein, the known human mutations associated with VOGMs are reviewed to provide a framework for future gene discovery. Gene mutations have been identified in 2 Mendelian syndromes of which VOGM is an infrequent but associated phenotype: capillary malformation-arteriovenous malformation syndrome ( RASA1) and hereditary hemorrhagic telangiectasia ( ENG and ACVRL1). However, these mutations probably represent only a small fraction of all VOGM cases. Traditional genetic approaches have been limited in their ability to identify additional causative genes for VOGM because kindreds are rare, limited in patient number, and/or seem to have sporadic inheritance patterns, attributable in part to incomplete penetrance and phenotypic variability. The authors hypothesize that the apparent sporadic occurrence of VOGM may frequently be attributable to de novo mutation or incomplete penetrance of rare transmitted variants. Collaboration among treating physicians, patients' families, and investigators using next-generation sequencing could lead to the discovery of novel genes for VOGM. This could improve the understanding of normal vascular biology, elucidate the pathogenesis of VOGM and possibly other more common arteriovenous malformation subtypes, and pave the way for advances in the diagnosis and treatment of patients with VOGM.
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http://dx.doi.org/10.3171/2017.9.PEDS17365DOI Listing
April 2018

Use of a pressure sensing sheath: comparison with standard means of blood pressure monitoring in catheterization procedures.

J Neurointerv Surg 2017 Aug 15;9(8):766-771. Epub 2016 Jul 15.

Department of Statistical Science, Southern Methodist University, Dallas, Texas, USA.

Purpose: Monitoring of blood pressure (BP) during procedures is variable, depending on multiple factors. Common methods include sphygmomanometer (BP cuff), separate radial artery catheterization, and side port monitoring of an indwelling sheath. Each means of monitoring has disadvantages, including time consumption, added risk, and signal dampening due to multiple factors. We sought an alternative approach to monitoring during procedures in the catheterization laboratory.

Methods: A new technology involving a 330 µm fiberoptic sensor embedded in the wall of a sheath structure was tested against both radial artery catheter and sphygmomanometer readings obtained simultaneous with readings recorded from the pressure sensing system (PSS). Correlations and Bland-Altman analysis were used to determine whether use of the PSS could substitute for these standard techniques.

Results: The results indicated highly significant correlations in systolic, diastolic, and mean arterial pressures (MAP) when compared against radial artery catheterization (p<0.0001), and MAP means differed by <4%. Bland-Altman analysis of the data suggested that the sheath measurements can replace a separate radial artery catheter. While less striking, significant correlations were seen when PSS readings were compared against BP cuff readings.

Conclusions: The PSS has competitive functionality to that seen with a dedicated radial artery catheter for BP monitoring and is available immediately on sheath insertion without the added risk of radial catheterization. The sensor is structurally separated from the primary sheath lumen and readings are unaffected by device introduction through the primary lumen. Time delays and potential complications from radial artery catheterization are avoided.
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http://dx.doi.org/10.1136/neurintsurg-2016-012536DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5583680PMC
August 2017

4D DSA a new technique for arteriovenous malformation evaluation: a feasibility study.

J Neurointerv Surg 2016 Mar 12;8(3):300-4. Epub 2015 Jan 12.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Background: The angioarchitectural features of an arteriovenous malformation (AVM) provide key information regarding natural history and treatment planning. Because of rapid filling and vascular overlap, two-dimensional (2D) and three-dimensional (3D) digital subtraction angiography (DSA) are often suboptimal for evaluation of these features. We have developed an algorithm that derives a series of fully time-resolved 3D DSA volumes (four-dimensional (4D) DSA) at up to 30 frames/s from a conventional 3D DSA. The temporal/spatial resolution of 4D reconstructions is significantly higher than that provided by current MR angiography and CT angiography techniques. 4D reconstruction allows viewing of an AVM from any angle at any time during its opacification. This feasibility study investigated the potential of 4D DSA to improve the ability to analyze angioarchitectural features compared with conventional 2D and 3D DSA.

Methods: 2D, 3D, and 4D DSA reconstructions of angiographic studies of six AVMs were evaluated by three cerebrovascular neurosurgeons and one interventional neuroradiologist. These observers evaluated the ability of each modality to visualize the angioarchitectural features of the AVMs. They also compared the information provided using the combination of 2D and 3D DSA with that provided by a 4D DSA reconstruction.

Results: By consensus, 4D DSA provided the best ability to visualize the internal features of the AVM including intranidal aneurysms, fistulae, venous obstructions, and sequence of filling and draining. 2D and 3D images in comparison were limited because of overlap of the vasculature.

Conclusions: In this small series, 4D DSA provided better ability to visualize the angioarchitecture of an AVM than conventional methods. Further experience is required to determine the ultimate utility of this technique.
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http://dx.doi.org/10.1136/neurintsurg-2014-011534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740248PMC
March 2016

Familial perimesencephalic subarachnoid hemorrhage: two case reports.

J Med Case Rep 2014 Nov 22;8:380. Epub 2014 Nov 22.

Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.

Introduction: Non-aneurysmal spontaneous subarachnoid hemorrhage is characterized by an accumulation of a limited amount of subarachnoid hemorrhage, predominantly around the midbrain, and a lack of blood in the brain parenchyma or ventricular system. It represents 5% of all spontaneous subarachnoid hemorrhage cases. In spite of extensive investigation, understanding of the mechanisms leading to perimesencephalic non-aneurysmal subarachnoid hemorrhage remains incompletely defined. A growing body of evidence has supported a familial predisposition for non-aneurysmal spontaneous subarachnoid hemorrhage.

Case Presentation: A 39-year-old Caucasian man presented with sudden onset headache associated with diplopia. His computed tomography scan revealed perimesencephalic subarachnoid hemorrhage. A cerebral angiogram showed no apparent source of bleeding. He was treated conservatively and discharged after 1 week without any neurological deficits. The older brother of the first case, a 44-year-old Caucasian man, presented 1.5 years later with acute onset of headache and his computed tomography scan also showed perimesencephalic non-aneurysmal subarachnoid hemorrhage. He was discharged home with normal neurological examination 1 week later. Follow-up angiograms did not reveal any source of bleeding in either patient.

Conclusions: We report the cases of two siblings with perimesencephalic non-aneurysmal subarachnoid hemorrhage, which may further suggest a familial predisposition of non-aneurysmal spontaneous subarachnoid hemorrhage and may also point out the possible higher risk of perimesencephalic non-aneurysmal subarachnoid hemorrhage in the first-degree relatives of patients with perimesencephalic non-aneurysmal subarachnoid hemorrhage.
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http://dx.doi.org/10.1186/1752-1947-8-380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4275759PMC
November 2014

Preliminary in vivo evaluation of a novel intrasaccular cerebral aneurysm occlusion device.

J Neurointerv Surg 2015 Aug 2;7(8):584-90. Epub 2014 Jun 2.

Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA.

Objective: Current endovascular technology does not offer a perfect solution for all cerebral aneurysms. Our group has built two versions of a novel aneurysm intrasaccular occlusion device (AIOD) to address the drawbacks associated with current occlusion devices. The objective of the present study was to perform pilot proof of concept in vivo testing of this new AIOD in swine and canines.

Methods: Two configurations of the AIOD, termed 'coil-in-shell' and 'gel-in-shell', were implanted in surgically created sidewall aneurysms (n=4) in swine for acute occlusion studies, as well as sidewall (n=8) and bifurcation aneurysms (n=3) in canines to assess long term occlusion efficacy. Occlusion at all time points (immediate, 6 weeks, and 12 weeks) was evaluated by angiography. Neointimal healing at 12 weeks post-implantation in canines was examined histologically.

Results: Angiographic analysis showed that both the coil-in-shell and gel-in-shell devices achieved complete aneurysm occlusion immediately following device delivery in sidewall aneurysms in swine. In longer term canine studies, initial occlusion ranged from 71.3% to 100%, which was stable with no recurrence in any of the sidewall aneurysms at 6 or 12 weeks. Histological analysis at 12 weeks showed mature fibromuscular tissue at the neck of all aneurysms and no significant inflammatory response.

Conclusions: The AIOD tested in this study showed promise in terms of acute and chronic occlusion of aneurysms. Our findings suggest that these devices have the potential to promote robust tissue healing at the aneurysm neck, which may minimize aneurysm recurrence. Although proof of principle has been shown, further work is needed to deliver this device through an endovascular route.
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http://dx.doi.org/10.1136/neurintsurg-2014-011179DOI Listing
August 2015

Extensive sinovenous thrombosis and hemorrhagic infarction during therapy for T-cell acute lymphoblastic leukemia.

Pediatr Emerg Care 2013 Jan;29(1):93-7

Department of Pediatrics, Loyola University Medical Center, Maywood, IL, USA.

Sinovenous thrombosis (SVT) is a well-recognized and serious complication in children treated for acute leukemia. This frequently occurs during or immediately upon completion of induction therapy and is commonly attributed to asparaginase therapy.Headache is the first and most common clinical symptom to occur during the early development of SVT. With advancement of the thrombosis, the clinical symptoms can progress to increased sleepiness, focal neurological deficit, seizures, and altered consciousness. We report the case of a 4-year-old girl who presented after several days of headaches and anorexia, which then progressed to seizures, left-sided weakness, and altered consciousness. She was later found to have a widespread and occlusive SVT with right cerebral hemorrhagic infarction. This case is notable for the extensive nature of the cerebral SVT and the child's complete clinical recovery from the neurological event. The report discusses the relation of the thrombosis and leukemia and also emphasizes the importance of early recognition and prompt management, while incorporating a collaborative multidisciplinary approach to prevent long-term consequences.
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http://dx.doi.org/10.1097/PEC.0b013e31827b5761DOI Listing
January 2013

Facial and lower cranial neuropathies after preoperative embolization of jugular foramen lesions with ethylene vinyl alcohol.

Otol Neurotol 2012 Sep;33(7):1270-5

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin 53792-7375, USA.

Objective: To report 3 unique cases of cranial neuropathy after super-selective arterial embolization of jugular foramen vascular tumors with ethylene vinyl alcohol.

Study Design: Clinical capsule report.

Setting: Three tertiary academic referral hospitals.

Patients: Three patients who underwent superselective arterial embolization (SSE) of head and neck paragangliomas with ethylene vinyl alcohol are described. One individual was treated with primary SSE, whereas the remaining tumors were treated with preoperative SSE followed by surgical extirpation within 72 hours. All patients were found to have new cranial nerve deficits after SSE.

Results: One patient with isolated complete cranial nerve VII palsy demonstrated partial return of function at 8 months. One individual experienced cranial nerve VII, X, and XII palsies and demonstrated partial recovery of function of the involved facial nerve after 19 months. One subject experienced ipsilateral cranial nerve X and XI palsies after SSE and recovered full function of the spinal accessory nerve within 1 week but failed to demonstrate mobility of the ipsilateral true vocal fold.

Conclusion: We present the first report documenting facial and lower cranial neuropathies after super-selective embolization of head and neck paragangliomas with EVA. Although it is difficult to draw conclusions from this small number of cases, it is plausible that the use of ethylene vinyl alcohol during SSE may result in a higher risk of permanent cranial neuropathy than the use of other well-established and more temporary agents. Knowledge of the arterial supply to the cranial nerves can help the clinician to choose the embolization agent that will provide maximal occlusion while minimizing the risk of complications.
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http://dx.doi.org/10.1097/MAO.0b013e31825f2365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3581607PMC
September 2012

U.S. Wingspan Registry: 12-month follow-up results.

Stroke 2011 Jul 2;42(7):1976-81. Epub 2011 Jun 2.

Stony Brook University Medical Center, Department of Neurological Surgery, Health Sciences Center T-12 080, Stony Brook, NY 11794, USA.

Background And Purpose: The purpose of this study is to present 12-month follow-up results for a series of patients undergoing percutaneous transluminal angioplasty and stenting with the Gateway-Wingspan stenting system (Boston Scientific) for the treatment of symptomatic intracranial atherostenosis.

Methods: Clinical and angiographic follow-up results were recorded for patients from 5 participating institutions. Primary end points were stroke or death within 30 days of the stenting procedure or ipsilateral stroke after 30 days.

Results: During a 21-month study period, 158 patients with 168 intracranial atherostenotic lesions (50% to 99%) were treated with the Gateway-Wingspan system. The average follow-up duration was 14.2 months with 143 patients having at least 3 months of clinical follow-up and 110 having at least 12 months. The cumulative rate of the primary end point was 15.7% for all patients and 13.9% for patients with high-grade (70% to 99%) stenosis. Of 13 ipsilateral strokes occurring after 30 days, 3 resulted in death. Of these strokes, 76.9% (10 of 13) occurred within the first 6 months of the stenting procedure and no events were recorded after 12 months. An additional 9 patients experienced ipsilateral transient ischemic attack after 30 days. Most postprocedural events (86%) could be attributed to interruption of antiplatelet medications (n=6), in-stent restenosis (n=12), or both (n=1). In 3 patients, the events were of uncertain etiology.

Conclusions: After successful Wingspan percutaneous transluminal angioplasty and stenting, some patients continued to experience ipsilateral ischemic events. Most of these ischemic events occurred within 6 months of the procedure and were associated with the interruption of antiplatelet therapy or in-stent restenosis.
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http://dx.doi.org/10.1161/STROKEAHA.111.613877DOI Listing
July 2011

Time resolved contrast enhanced intracranial MRA using a single dose delivered as sequential injections and highly constrained projection reconstruction (HYPR CE).

Magn Reson Med 2011 Apr 17;65(4):956-63. Epub 2011 Feb 17.

Department of Medical Physics, University of Wisconsin, Madison, Wisconsin 53705, USA.

Time-resolved contrast-enhanced magnetic resonance angiography of the brain is challenging due to the need for rapid imaging and high spatial resolution. Moreover, the significant dispersion of the intravenous contrast bolus as it passes through the heart and lungs increases the overlap between arterial and venous structures, regardless of the acquisition speed and reconstruction window. An innovative technique is presented that divides a single dose contrast into two injections. Initially a small volume of contrast material (2-3 mL) is used to acquiring time-resolved weighting images with a high frame rate (2 frames/s) during the first pass of the contrast agent. The remaining contrast material is used to obtain a high resolution whole brain contrast-enhanced (CE) magnetic resonance angiography (0.57 × 0.57 × 1 mm(3) ) that is used as the spatial constraint for Local Highly Constrained Projection Reconstruction (HYPR LR) reconstruction. After HYPR reconstruction, the final dynamic images (HYPR CE) have both high temporal and spatial resolution. Furthermore, studies of contrast kinetics demonstrate that the shorter bolus length from the reduced contrast volume used for the first injection significantly improves the arterial and venous separation.
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http://dx.doi.org/10.1002/mrm.22792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219433PMC
April 2011

A simple technique for interventional tool placement combining fluoroscopy with interventional computed tomography on a C-arm system.

Neurosurgery 2010 Sep;67(3 Suppl Operative):ons49-56; discussion ons56-7

Department of Medical Physics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin 53705, USA.

Background: Flat-panel cone-beam computed tomography (FP-CBCT) has recently been introduced as a clinical feature in neuroangiography radiographic C-arm systems.

Objective: To introduce a method of positioning a surgical tool such as a needle or ablation probe within a target specified by intraoperative FP-CBCT scanning.

Methods: Two human cadaver and 2 porcine cadaver heads were injected with a mixture of silicone and contrast agent to simulate a contrast-enhanced tumor. Preoperative imaging was performed using a standard 1.5-T magnetic resonance imaging scanner. Intraoperative imaging was used to define the needle trajectory on a GE Innova 4100 flat panel-based neuroangiography C-arm system.

Results: Using a combination of FP-CBCT and fluoroscopy, a needle was successfully positioned within each of the simulated contrast-enhanced tumors, as verified by subsequent FP-CBCT scans.

Conclusions: This proof-of-concept study demonstrates the potential utility of combining FP-CBCT scanning with fluoroscopy to position surgical tools when stereotactic devices and image-guided surgery systems are not available. However, further work is required to fully characterize the precision and accuracy of the method in a variety of realistic surgical sites.
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http://dx.doi.org/10.1227/01.NEU.0000382976.18891.50DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6758548PMC
September 2010

Outcome of symptomatic intracranial atherosclerotic disease.

Stroke 2009 Sep 25;40(9):2983-7. Epub 2009 Jun 25.

Department of Neurology, University of Wisconsin-Madison, Madison, Wisc, USA.

Background And Purpose: Patients with intracranial atherosclerotic disease have a 3.6% to 22% annual risk of stroke. In this study, we sought to evaluate the natural history and prognosis of patients with symptomatic intracranial atherosclerotic disease who received medical therapy versus percutaneous transluminal angioplasty and stenting (PTAS) at our institution.

Methods: Charts of all patients with symptomatic intracranial atherosclerotic disease from July 2004 to September 2007 were reviewed and assessed for history of transient ischemic attack or stroke. Patients were either treated with "best medical therapy" (Medical Therapy Group) or PTAS plus antiplatelet agents (PTAS Group) and followed prospectively. A favorable outcome was defined as the absence of transient ischemic attacks, strokes, or vascular death; modified Rankin Scale of < or =3; and no endovascular reintervention of symptomatic in-stent restenosis.

Results: One hundred eleven patients fulfilled entry criteria, with 58 (52.3%) and 53 patients (47.7%) enrolled in the Medical Therapy and PTAS Groups, respectively. Thirty-eight patients of the Medical Therapy Group (65.5%) had a favorable outcome compared with 37 patients of the PTAS Group (69.8%). Combined ischemic end point data for the occurrence of transient ischemic attack, stroke, and vascular death was similar with 14 (24%) events in the Medical Therapy Group versus 15 (28.3%) events in the PTAS Group.

Conclusions: Overall, the combined ischemic end point was the same in the Medical Therapy and PTAS Groups.
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http://dx.doi.org/10.1161/STROKEAHA.109.549972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770373PMC
September 2009

Target lesion revascularization after wingspan: assessment of safety and durability.

Stroke 2009 Jan 16;40(1):106-10. Epub 2008 Oct 16.

Barrow Neurosurgical Associates, Ltd, Phoenix-Main Office, 2910 N. 3 Avenue, Phoenix, AZ 85013, USA.

Background And Purpose: In-stent restenosis (ISR) occurs in approximately one-third of patients after the percutaneous transluminal angioplasty and stenting of intracranial atherosclerotic lesions with the Wingspan system. We review our experience with target lesion revascularization (TLR) for ISR after Wingspan treatment.

Methods: Clinical and angiographic follow-up results were recorded for all patients from 5 participating institutions in our US Wingspan Registry. ISR was defined as >50% stenosis within or immediately adjacent (within 5 mm) to the implanted stent and >20% absolute luminal loss.

Results: To date, 36 patients in the registry have experienced ISR after percutaneous transluminal angioplasty and stenting with Wingspan. Of these patients, 29 (80.6%) have undergone TLR with either angioplasty alone (n=26) or angioplasty with restenting (n=3). Restenting was performed for in-stent dissections that occurred after the initial angioplasty. Of the 29 patients undergoing TLR, 9 required >/=1 interventions for recurrent ISR, for a total of 42 interventions. One major complication, a postprocedural reperfusion hemorrhage, was encountered in the periprocedural period (2.4% per procedure; 3.5% per patient). Angiographic follow-up is available for 22 of 29 patients after TLR. Eleven of 22 (50%) demonstrated recurrent ISR at follow-up angiography. Nine patients have undergone multiple retreatments (2 retreatments, n=6; 3 retreatments, n=2; 4 retreatments, n=1) for recurrent ISR. Nine of 11 recurrent ISR lesions were located within the anterior circulation. The mean age for patients with recurrent anterior circulation ISR was 57.9 years (vs 81 years for posterior circulation ISR).

Conclusions: TLR can be performed for the treatment of intracranial Wingspan ISR with a relatively high degree of safety. However, the TLR results are not durable in approximately 50% of patients, and multiple revascularization procedures may be required in this subgroup.
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http://dx.doi.org/10.1161/STROKEAHA.108.525774DOI Listing
January 2009

Angiographic patterns of Wingspan in-stent restenosis.

Neurosurgery 2008 Jul;63(1):23-7; discussion 27-8

Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.

Objective: A classification system developed to characterize in-stent restenosis (ISR) after coronary percutaneous transluminal angioplasty with stenting was modified and applied to describe the appearance and distribution of ISR occurring after Wingspan (Boston Scientific, Fremont, CA) intracranial percutaneous transluminal angioplasty with stenting.

Methods: A prospective, intention-to-treat, multicenter registry of Wingspan treatment for symptomatic intracranial atherosclerotic disease was maintained. Clinical and angiographic follow-up results were recorded. ISR was defined as greater than 50% stenosis within or immediately adjacent (within 5 mm) to the implanted stent(s) and greater than 20% absolute luminal loss. ISR lesions were classified by angiographic pattern, location, and severity in comparison with the original lesion treated.

Results: Imaging follow-up (3-15.5 months) was available for 127 intracranial stenotic lesions treated with Wingspan percutaneous transluminal angioplasty with stenting. Forty-one lesions (32.3%) developed either ISR (n = 36 [28.3%]) or complete stent occlusion (n = 5 [3.9%]) after treatment. When restenotic lesions were characterized using the modified classification system, 25 of 41 (61.0%) were focal lesions involving less than 50% of the length of the stented segment: three were Type IA (focal stenosis involving one end of the stent), 21 were Type IB (focal intrastent stenosis involving a segment completely contained within the stent), and one was Type IC (multiple noncontiguous focal stenoses). Eleven lesions (26.8%) demonstrated diffuse stenosis (>50% of the length of the stented segment): nine were Type II with diffuse intrastent stenosis (completely contained within the stent) and two were Type III with proliferative ISR (extending beyond the stented segment). Five stents were completely occluded at follow-up (Type IV). Of the 36 ISR lesions, 16 were less severe or no worse than the original lesion with respect to severity of stenosis or length of the segment involved; 20 lesions were more severe than the original lesion with respect to the segment length involved (n = 5), actual stenosis severity (n = 6), or both (n = 9). Nine of 10 supraclinoid internal carotid artery ISR lesions and nine of 13 middle cerebral artery ISR lesions were more severe than the original lesion.

Conclusion: Wingspan ISR typically occurs as a focal lesion. In more than half of ISR cases, the ISR lesion was more extensive than the original lesion treated in terms of lesion length or stenosis severity. Supraclinoid internal carotid artery and middle cerebral artery lesions have a propensity to develop more severe posttreatment stenosis.
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http://dx.doi.org/10.1227/01.NEU.0000335067.53190.A2DOI Listing
July 2008

Frequency of thromboembolic events associated with endovascular aneurysm treatment: retrospective case series.

J Neurosurg 2008 Jun;108(6):1095-100

Department of Neurological Surgery, University of Wisconsin at Madison, WI, USA.

Object: There is little evidence addressing whether procedures requiring adjunctive devices lead to an increased frequency of thromboembolic complications. The authors report their experience with 155 aneurysms treated with and without adjunctive devices.

Methods: The authors retrospectively reviewed their last 155 aneurysm coil placement procedures. The patients' records were reviewed for the following phenomena: 1) evidence of procedure-related thrombus formation; 2) clinical evidence of stroke; and 3) the presence of acute ischemia in the treated vascular territory on diffusion-weighted (DW) imaging.

Results: Of the 155 aneurysms treated in 132 patients, 66 were treated with coils only, 45 had stent-assisted coil placement, 33 underwent balloon remodeling, and in 11 stents were placed after balloon remodeling. Small DW imaging abnormalities were present in the treated vascular territory in 24% of cases (37 lesions). Specifically, 21 (32%) of 66 lesions in the coil-treated group, 6 (13%) of 45 in the stent-assisted coil treatment group, 8 (24%) of 33 in the balloon remodeling group, and 2 (18%) of 11 in the balloon and stent group showed DW imaging positivity. Furthermore, 25 (68%) of the 37 cases that were positive on DW imaging occurred in patients presenting with subarachnoid hemorrhage (SAH). Clinically evident stroke or transient ischemic attack was present in 10 (27%) of 37 cases, with 70% occurring in patients presenting with SAH.

Conclusions: Use of adjunctive devices in treating aneurysms does not appear to increase the frequency of embolic or ischemic events. The presence of DW imaging abnormalities and clinically evident stroke was actually less frequent when adjunctive devices were used and in electively treated cases. This was probably related to perioperative antiplatelet medical management.
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http://dx.doi.org/10.3171/JNS/2008/108/6/1095DOI Listing
June 2008

Wingspan in-stent restenosis and thrombosis: incidence, clinical presentation, and management.

Neurosurgery 2007 Sep;61(3):644-50; discussion 650-1

Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York, USA.

Objective: Wingspan (Boston Scientific, Fremont, CA) is a self-expanding stent designed specifically for the treatment of symptomatic intracranial atheromatous disease. The current series reports the observed incidence of in-stent restenosis (ISR) and thrombosis on angiographic follow-up.

Methods: A prospective, intent-to-treat registry of patients in whom the Wingspan stent system was used to treat symptomatic intracranial atheromatous disease was maintained at five participating institutions. Clinical and angiographic follow-up results were recorded. ISR was defined as stenosis greater than 50% within or immediately adjacent (within 5 mm) to the implanted stents and absolute luminal loss greater than 20%.

Results: To date, follow-up imaging (average duration, 5.9 mo; range, 1.5-15.5 mo) is available for 84 lesions treated with the Wingspan stent (78 patients). Follow-up examinations consisted of 65 conventional angiograms, 17 computed tomographic angiograms, and two magnetic resonance angiograms. Of these lesions with follow-up, ISR was documented in 25 and complete thrombosis in four. Two of the 4 patients with stent thrombosis had lengthy lesions requiring more than one stent to bridge the diseased segment. ISR was more frequent (odds ratio, 4.7; 95% confidence intervals, 1.4-15.5) within the anterior circulation (42%) than the posterior circulation (13%). Of the 29 patients with ISR or thrombosis, eight were symptomatic (four with stroke, four with transient ischemic attack) and 15 were retreated. Of the retreatments, four were complicated by clinically silent in-stent dissections, two of which required the placement of a second stent. One was complicated by a postprocedural reperfusion hemorrhage.

Conclusion: The ISR rate with the Wingspan stent is higher in our series than previously reported, occurring in 29.7% of patients. ISR was more frequent within the anterior circulation than the posterior circulation. Although typically asymptomatic (76% of patients in our series), ISR can cause neurological symptoms and may require target vessel revascularization.
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http://dx.doi.org/10.1227/01.NEU.0000290914.24976.83DOI Listing
September 2007

Utilization of self-expanding stents in the treatment of intracranial atherosclerotic disease in the distal small cerebral vessels.

Neuroradiology 2007 Aug 27;49(8):659-63. Epub 2007 Mar 27.

Department of Neurosurgery, University of Wisconsin Hospital and Clinics, 600 Highland Ave., Madison, WI, USA.

Introduction: Previously, endovascular treatment of stenosis related to intracranial atherosclerosis (ICAD) involving arteries measuring less than 2 mm in diameter was limited. To our knowledge, there are no reports in the literature addressing stent placement for treatment of stenosis in arteries of this size.

Methods: Four patients aged 33 to 80 years (mean 57.5 years) with medically refractory ICAD underwent angioplasty and stenting of small (<2 mm) distal intracerebral arteries. Vessel location and length of follow-up were anterior cerebral artery (ACA) A1 segment (5 months), ACA A2 segment (18 months), middle cerebral artery M1 segment (18 months), and posterior cerebral artery P1 segment (8 months) with vessel calibers ranging from 1.2 to 1.8 mm. Clinical and imaging follow-up ranged from 5 to 18 months.

Results: All procedures were successfully performed without complications. Follow-up out to 18 months demonstrated one vessel that went on to occlusion while the other stented vessel segments remained patent. One patient died 8 months after stenting, but the death was not related to neurological disease. The remaining patients experienced resolution of the presenting symptomatology and remained asymptomatic throughout follow-up.

Conclusion: In this small series, stenoses of distal (<2 mm) cerebral arteries were amenable to treatment using new self-expanding stents. We safely and successfully treated four arteries smaller than 2 mm in diameter with newer self-expanding stents. All patients remained clinically asymptomatic. One stent occluded at 5 months and the others remained patent during follow-up. Longer term clinical follow-up is required to determine the durability and viability of this therapy.
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http://dx.doi.org/10.1007/s00234-007-0229-xDOI Listing
August 2007

US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results.

Stroke 2007 Mar 8;38(3):881-7. Epub 2007 Feb 8.

Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

Background And Purpose: The current report details our initial periprocedural experience with Wingspan (Boston Scientific/Target), the first self-expanding stent system designed for the treatment of intracranial atheromatous disease.

Methods: All patients undergoing angioplasty and stenting with the Gateway balloon-Wingspan stent system were prospectively tracked.

Results: During a 9-month period, treatment with the stent system was attempted in 78 patients (average age, 63.6 years; 33 women) with 82 intracranial atheromatous lesions, of which 54 were > or =70% stenotic. Eighty-one of 82 lesions were successfully stented (98.8%) during the first treatment session. In 1 case, the stent could not be delivered across the lesion; the patient was treated solely with angioplasty and stented at a later date. Lesions treated involved the internal carotid (n=32; 8 petrous, 10 cavernous, 11 supraclinoid segment, 3 terminus), vertebral (n=14; V4 segment), basilar (n=14), and middle cerebral (n=22) arteries. Mean+/-SD pretreatment stenosis was 74.6+/-13.9%, improving to 43.5+/-18.1% after balloon angioplasty and to 27.2+/-16.7% after stent placement. Of the 82 lesions treated, there were 5 (6.1%) major periprocedural neurological complications, 4 of which ultimately led to patient death within 30 days of the procedure.

Conclusions: Angioplasty and stenting for symptomatic intracranial atheromatous disease can be performed with the Gateway balloon-Wingspan stent system with a high rate of technical success and acceptable periprocedural morbidity. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.
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http://dx.doi.org/10.1161/01.STR.0000257963.65728.e8DOI Listing
March 2007

Utility of computed tomography perfusion in detection of cerebral vasospasm in patients with subarachnoid hemorrhage.

Neurosurg Focus 2006 Sep 15;21(3):E6. Epub 2006 Sep 15.

Department of Neurosurgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA.

Object: Digital subtraction (DS) angiography is the gold standard for detecting cerebral vasospasm after subarachnoid hemorrhage (SAH). Computed tomography (CT) perfusion is a recently developed modality for the evaluation of cerebral hemodynamics. This study was conducted to evaluate the potential of using CT perfusion to detect vasospasm in patients with SAH.

Methods: Fourteen patients between the ages of 41 and 66 years with aneurysmal SAH underwent 23 CT perfusion scans for suspected vasospasm. All patients underwent DS angiography within 12 hours of the CT perfusion scans. The presence of vasospasm on CT perfusion images was determined based on qualitative reading using color maps of mean transit time, cerebral blood flow, and cerebral blood volume as criteria. The presence or absence of vasospasm as retrospectively determined using CT perfusion was compared with DS angiography findings. Of the 23 CT perfusion scans performed, 21 (91%) were concordant with angiography findings in predicting the presence or absence of vasospasm. In 15 of 23 scans, the presence of vasospasm was detected on CT perfusion scans and confirmed on DS angiography studies. In two cases, vasospasm was revealed on DS angiography but was not confirmed on CT perfusion. The degree of agreement between CT perfusion and DS angiography for detection of vasospasm was high (K = 0.8, p , 0.0001).

Conclusions: Computed tomography perfusion is an accurate, reliable, and noninvasive method to detect the presence or absence of vasospasm. It can be used as a tool to help guide the decision to pursue DS angiography with the intent to treat vasospasm.
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http://dx.doi.org/10.3171/foc.2006.21.3.6DOI Listing
September 2006

Unilateral eyelid swelling and ptosis caused by dural arteriovenous fistula in an infant.

Arch Ophthalmol 2006 Sep;124(9):1359-61

Waisman Center, 1500 Highland Avenue, Madison, WI 53705, USA.

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http://dx.doi.org/10.1001/archopht.124.9.1359DOI Listing
September 2006

Effects of carotid or vertebrobasilar stent placement on cerebral perfusion and cognition.

AJNR Am J Neuroradiol 2005 Aug;26(7):1772-80

Department of Neurosurgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA.

Introduction: There are no well-established physiologic or neuropsychological criteria for identifying which patients with stenosis of the cervicocerebral vessels are at high risk of stroke or cognitive impairment. Our purpose was to evaluate changes in cognitive performance and cerebral perfusion associated with endovascular stent placement of the cervicocerebral vessels.

Methods: A consecutive series of 20 patients, 31-88 years of age, who underwent 21 stent procedures for arterial stenosis (10 extracranial carotid stents [ECS], four intracranial carotid stents [ICS], and seven extra- or intracranial vertebrobasilar stents [VBS]) was investigated retrospectively. All patients were evaluated with CT or MR perfusion studies both before and after stent placement. Cognitive response after stent placement was evaluated by using an informant questionnaire.

Results: In patients with anterior circulation stenoses (ECS and ICS group), 11 of 14 (79%) had a baseline perfusion abnormality and all 11 patients showed improved perfusion after stent placement. Four of seven (57%) patients with posterior circulation stenoses (VBS group) had a baseline perfusion abnormality and two of the four patients showed improved perfusion after stent placement. Degree of stenosis was the strongest predictor of the presence of a baseline perfusion abnormality (P = .03). Fifteen of 19 (79%) of the patients showed improved cognitive scores after stent placement. Among patients with improvement in perfusion after stent placement, 11 of 13 (85%) had improved cognitive scores. Improved perfusion after stent placement was a significant predictor of cognitive improvement (P = .04). Patients who were stented on an elective basis demonstrated greater improvement in cognition as compared with patients stented urgently (P = .01).

Conclusion: Endovascular stent placement of the cervicocerebral vessels can safely and effectively resolve cerebral perfusion abnormalities. Improvement in perfusion parameters is associated with cognitive improvement. Larger, blinded, prospective studies are needed to confirm these preliminary observations.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7975161PMC
August 2005

Intracranial endovascular stent placement for symptomatic metastatic non-hodgkin lymphoma. Case report.

J Neurosurg 2005 May;102(5):922-6

Department of Neurosurgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA.

A case of cranial-based metastatic non-Hodgkin lymphoma with cerebral vascular compromise is presented. The patient underwent intracranial endovascular stent placement resulting in an improvement in his symptoms. This is the first reported case of endovascular stent placement for an intracranial neoplasm in the literature to date.
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http://dx.doi.org/10.3171/jns.2005.102.5.0922DOI Listing
May 2005
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