Publications by authors named "Thomas J Masaryk"

45 Publications

Spinal Dural Arteriovenous Fistula: Diagnosis, Outcomes, and Prognostic Factors.

World Neurosurg 2020 12 25;144:e306-e315. Epub 2020 Aug 25.

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

Objective: Typically, the clinical presentation of a spinal dural arteriovenous fistula (SDAVF) will be insidious, with patients' symptoms regularly attributed to other conditions. Although previous studies have characterized the neurologic outcomes after treatment for SDAVFs, little is known about the pretreatment patient characteristics associated with poor and/or positive patient outcomes. We sought to characterize the pretreatment patient demographics, diagnostic history, and neurologic outcomes of patients treated for SDAVFs and to identify the patient factors predictive of these outcomes.

Methods: The medical records of patients who had been treated for SDAVFs from 2006 to 2018 across 1 healthcare system were retrospectively analyzed. Neurologic status was assessed both before and after intervention using the Aminoff-Logue scales for gait and micturition disturbances.

Results: Of 46 total patients, 16 (35%) had a documented misdiagnosis. Patients with a history of misdiagnosis had had a significantly longer symptom duration before treatment compared with those without a misdiagnosis (median, 2.3 vs. 0.9 years; P = 0.018). A shorter symptom duration before intervention was significantly associated with both improved motor function (median, 0.8 vs. 3.1 years; P = 0.001) and improved urinary function (median, 0.8 vs. 2.2 years; P = 0.040) after intervention.

Conclusions: Misdiagnosis has been relatively common in patients with SDAVFs and contributes to delays in treatment. Delays in diagnosis and treatment of SDAVFs appear to be associated with worse clinical outcomes for patients who, ultimately, receive treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.08.126DOI Listing
December 2020

Early post-Humanitarian Device Exemption experience with the Neuroform Atlas stent.

J Neurointerv Surg 2019 Nov 12;11(11):1141-1144. Epub 2019 Apr 12.

Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA.

Introduction: The low-profile Neuroform Atlas stent received FDA Humanitarian Device Exemption status (HDE) in January 2018 for stent-assisted coil embolization of wide-necked saccular aneurysms. We review and report our results with the Atlas stent in our institution within the first year after its HDE approval.

Methods: Our retrospective chart review identified patients treated with the Atlas stent. We analyzed the patient demographics, aneurysm characteristics, stent parameters and configuration, complications, angiographic, and clinical outcomes at discharge.

Results: From January to December 2018, 76 Atlas stents were deployed in 58 patients (average 1.3 stents/patient). Median patient age was 63.5 (IQR 56-71) years. Fifty-six (96.6%) patients had elective embolization of unruptured aneurysms, while two (3.4%) patients underwent embolization of a ruptured aneurysm within 2 weeks of subarachnoid hemorrhage. Forty (69.0%) patients were treated with a single stent, 15 (25.9%) with a Y-stent, and three (5.2%) with X-stent configuration. All stent deployments were technically successful. Most stents (82.9%) were the smallest 3 mm diameter devices. Procedural complications included transient stent-associated thrombosis in three (5.2%) patients and aneurysm rupture in one (1.7%). None had distal embolization, associated cerebral infarction, or permanent neurological deficits. Immediate Raymond-Roy 1 occlusion was achieved in 41 (70.7%) patients. Median hospital length of stay for elective aneurysm embolization was 1 day. Excellent outcomes with median National Institute of Health Stroke Scale score 0 (IQR 0-0) and modified Rankin Score 0 (IQR 0-1) were seen for elective patients at discharge.

Conclusion: The Neuroform Atlas stent provided a reliable technical and safety profile for the treatment of intracranial wide-neck aneurysms. Further experience is needed to determine long-term durability and safety of this device.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2019-014874DOI Listing
November 2019

Long-term Follow-up of In-stent Stenosis After Pipeline Flow Diversion Treatment of Intracranial Aneurysms.

Neurosurgery 2016 Jun;78(6):862-7

Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio.

Background: There is scant information on in-stent stenosis after flow diversion treatment of intracranial aneurysms with the Pipeline Embolization Device (PED).

Objective: To assess the incidence, severity, nature, and clinical consequences of in-stent stenosis on angiographic follow-up after treatment with the PED.

Methods: A retrospective study of patients who underwent aneurysm treatment with the PED was conducted. In-stent stenosis was assessed on subsequent follow-up angiography. Intimal hyperplasia was defined as a uniform growth process beyond the limits of the metallic mesh at <25%. In-stent stenosis represented an area of parent vessel narrowing, most often focal, graded as mild (25%-50%), moderate (50%-75%), or severe (>75%).

Results: Between June 2011 and April 2015, 80 patients were treated with the PED. Angiographic follow-up was available for 51 patients (representing 76% of available or 64% of all patients). Mean follow-up was 12.5 months. In-stent stenosis was detected in 5 patients (9.8%) at a median of 6 months. Stenosis was mild in 4 of 5 (80%) and moderate in 1 of 5 (20%) patients. There were no cases of severe stenosis. No stenosis caused flow limitation, clinical symptoms, or required re-treatment. Additional follow-up angiography was available in 2 of 5 stenosis patients showing marked improvement. Sixteen patients (31%) had intimal hyperplasia, and 28 patients (55%) had no stenosis. Asymptomatic stent occlusion occurred in 2 patients (4%) related to medication noncompliance.

Conclusion: Treatment with the PED was associated with a 9.8% rate of in-stent stenosis, detected on first angiographic follow-up, at a median of 6 months. None were symptomatic or required re-treatment, and they showed significant improvement on follow-up.

Abbreviation: FD, flow diverter.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/NEU.0000000000001146DOI Listing
June 2016

The location of pretreatment hyperdense middle cerebral artery sign predicts the outcome of intraarterial thrombectomy for acute stroke.

J Neuroimaging 2015 Mar-Apr;25(2):263-268. Epub 2014 Apr 7.

Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH.

Background And Purpose: Intraarterial (IA) mechanical thrombectomy has an excellent recanalization rate but does not always correlate with good clinical outcomes. We aimed to investigate whether hyperdense middle cerebral artery sign (HMCAS) on preintervention nonenhanced CT (NECT) predicts IA therapy outcome for acute stroke.

Methods: Data were abstracted from our Hyperacute Ischemic Stroke database. Patients with occlusion in ICA, MCA, or MCA M2 branches who underwent IA therapy were included.

Results: Among 126 patients who underwent IA treatment, 64 (51%) had hyperdense M1 MCA sign (M1 HMCAS), 11 (9%) had hyperdense M2, and 51 (40%) had No HMCAS (NHMCAS).M1 HMCAS and NHMCAS group has comparable baseline stroke severity and infarct volume (P > .05); and the differences of favorable outcome (modified Rankin Score 0-2) at 30 days were not significant (21% vs. 30%, P = .259). For those with HMCAS, favorable 30-day outcome was most frequent in Distal HMCAS (39%), followed by hyperdense M2 (27%), HMCAS proximal (11%), and HMCAS full length (0%).

Conclusions: For acute ischemic stroke due to large vessel occlusion, the lack of HMCAS on NECT does not predict favorable outcome after IA therapy. Among those with HMCAS, proximal and longer HMCAS predicts unfavorable outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jon.12115DOI Listing
April 2016

A history of detachable coils: 1987-2012.

J Neurointerv Surg 2014 Mar 13;6(2):134-8. Epub 2013 Feb 13.

Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA.

Background: The development of detachable coils is one of the most pivotal developments in neurointervention, providing a tool that could be used to treat a wide variety of hemorrhagic stroke. From the original Guglielmi detachable coil, a number of different coil designs and delivery designs have evolved. This article reviews the history of commercially available detachable coils.

Methods: A timeline of detachable coils was constructed and coil design philosophies were reviewed.

Results: A complete list of commercially available coils is presented in a timeline format.

Conclusions: Detachable coil technology continues to evolve. Advances in construction and design have yielded products which may benefit patients in terms of safety, radiation dose reduction and cost of treatment. Continued evolution is expected, irrespective of competing disruptive technologies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2013-010670DOI Listing
March 2014

Simulated diagnostic cerebral angiography in neurosurgical training: a pilot program.

J Neurointerv Surg 2013 Jul 10;5(4):376-81. Epub 2012 May 10.

Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.

Introduction: Surgical simulation provides a zero-risk setting in which technical skills can be obtained through repetition. The feasibility and utility of simulated diagnostic cerebral angiography among neurosurgical residents and fellows was studied using an endovascular biplane angiography simulator.

Methods: Ten neurosurgical residents and four endovascular neurosurgery fellows were recruited into a standardized training protocol consisting of a didactic, demonstration and hands-on learning environment using the Simbionix simulator. Participants were instructed to catheterize the right internal carotid artery, left internal carotid artery and left vertebral artery. The task was repeated five times.

Results: All participants demonstrated improvement over the five trials. Residents performed actions that were perceived as potentially dangerous (n=8) while fellows performed the procedure with superior technique. Residents performed the task with an initial total procedure and fluoroscopy time of 6.6 ± 4.3 min and 4.9 ± 3.7 min, respectively, and improved on the fifth trial to 3.4 ± 1.3 min (p=0.03) and 2.3 ± 0.78 min (p=0.004), respectively. Residents approximated the efficiency of fellows for the third and fourth trial.

Conclusions: Incorporating an endovascular simulator is feasible for training purposes in a neurosurgical residency program. This study provides objective documentation of the facilitation of technical angiography skill acquisition by the use of simulation technology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2012-010319DOI Listing
July 2013

Balloon-augmented Onyx embolization of a dural arteriovenous fistula arising from the neuromeningeal trunk of the ascending pharyngeal artery: technical report.

J Neurointerv Surg 2011 Sep 8;3(3):300-3. Epub 2010 Dec 8.

Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA.

Introduction: Intracranial dural arteriovenous fistulas (dAVFs) with perimedullary drainage are an uncommon but well-recognized lesion that can lead to spinal cord edema. The authors present a case of a foramen magnum dAVF with unilateral arterial supply from the ascending pharyngeal artery.

Presentation: A 49-year-old male presented with a 1-year history of slowly progressive lower extremity weakness and underwent a two-level cervical corpectomy for presumed spondylotic myelopathy. On further workup, he was found to have a dAVF arising from the ascending pharyngeal artery.

Intervention: Selective angiography revealed the origin of the neuromeningeal trunk, which was proximal to the arteriovenous fistula. The microcatheter was advanced into the neuromeningeal trunk past the origin of the inferior tympanic artery and origin of the hypoglossal artery. A 4×7 mm Hyperform balloon (EV3, Irvine, California, USA) was then delivered past the origin of the vessel supplying the skull base cranial nerves, but proximal to the microcatheter tip. The balloon was inflated and Onyx embolization was employed to obliterate the fistula with controlled penetration. The patient showed immediate postprocedural improvement in motor function.

Discussion: Embolization of branches of the ascending pharyngeal artery carries risks of inadvertent embolization of branches of the neuromeningeal trunk as well as the risk for extracranial to intracranial anastamoses. An awareness of the highly variable anatomy of the ascending pharyngeal artery is necessary for the safe treatment of lesions supplied by this artery. This is, to the authors' knowledge, the first report of balloon-augmented embolization of an arteriovenous fistula arising from the neuromeningeal trunk.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/jnis.2010.003095DOI Listing
September 2011

Combined endovascular and surgical resection of a giant lumbosacral arteriovenous malformation in a patient with Cobb syndrome.

J Neurointerv Surg 2011 Sep 6;3(3):293-6. Epub 2011 Apr 6.

Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.

Objective And Importance: Cobb syndrome is a rare condition that includes a cutaneous nevus with an associated spinal vascular lesion at the same dermatome. We present a challenging case of a progressively symptomatic massive lumbosacral arteriovenous malformation (AVM) in a patient with Cobb's syndrome requiring a multimodality approach including staged preoperative transarterial and transvenous endovascular embolization followed by surgical excision and wound reconstruction.

Clinical Presentation: The patient presented with a massive lumbosacral AVM with symptoms of congestive heart failure. Angiography demonstrated arterial feeders predominantly from internal iliac, median sacral and lumbar segmental arteries.

Intervention: The patient underwent staged transarterial and transvenous endovascular embolization resulting in 90% reduction in the AVM size, followed by surgical resection of the lesion. The patient made an excellent recovery with improvement in his symptoms of congestive heart failure.

Conclusion: The treatment algorithm for massive AVMs must be individualized. A combination of staged embolization and subsequent surgery may be required to obtain a good result. Through this carefully planned multidisciplinary approach a previously incurable lesion in this patient with Cobb syndrome was able to be treated successfully.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/jnis.2010.002972DOI Listing
September 2011

Thromboembolic events associated with endovascular treatment of cerebral aneurysms.

J Neurointerv Surg 2011 Jun 8;3(2):147-50. Epub 2011 Jan 8.

Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA.

Objective: To evaluate the rate of peri-procedural thromboembolic events after the endovascular treatment of cerebral aneurysms. The rate of diffusion-positive lesions was assessed in relation to selected procedural and technical factors.

Methods: 184 patients treated with coil embolization (198 total procedures) between July 2004 and February 2007 were included. In 65, the procedure was coiling alone; in 55, coiling with balloon remodeling; in 48, coiling with Neuroform stenting; and in 30, coiling, Neuroform stenting and balloon remodeling. All patients underwent a routine diffusion weighted magnetic resonance imaging (DWI) within the 72 h after the intervention for the detection of ischemic complications.

Results: Regardless of the technique used, thromboembolic complications were more common (p<0.0001) in patients with ruptured aneurysms (33/65, 51%) than in those with unruptured aneurysms (40/133, 30%). Balloon remodeling tended to be associated with a lower rate of DWI positivity than the other techniques. Younger patients (≤60) with unruptured aneurysms had the lowest rates of DWI lesions regardless of the technique used.

Conclusion: In this study, peri-procedural DWI-positive lesions occurred in approximately one-third of all cases. These were threefold more common in the setting of ruptured aneurysms. Adjunctive devices did not increase the rate of ischemic events. On the contrary, there was a trend toward fewer DWI abnormalities in the procedures in which balloon remodeling was employed. This may, in part, be related to the application of the conglomerate coil mass technique of balloon remodeling.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/jnis.2010.003616DOI Listing
June 2011

Particle embolization of the bilateral superior and inferior alveolar arteries for life threatening dental socket hemorrhage.

J Neurointerv Surg 2012 Jul 9;4(4):e20. Epub 2011 Aug 9.

Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Particle embolization for epistaxis and intra-oral hemorrhage are performed on an as needed basis by neurointerventionalists. A case is presented of massive oral hemorrhage associated with end stage liver disease coagulopathy after tooth extraction of bilateral maxillary and mandibular molars. A man in his fifties with end stage liver disease who presented for evaluation of a syncopal episode was determined to be in hemorrhagic shock from 2 days of persistent oral bleeding after elective tooth extractions. Conservative management with multiple blood transfusion products, packing and vasoconstrictive spray was ineffective. Microcatheter angiograms of the alveolar arteries demonstrated blood and contrast pooling within the sockets of the extracted teeth. Selection of the bilateral supplying alveolar and inferior alveolar artery branches was achieved followed by polyvinyl alcohol particle embolization (250-355 μm). Polyvinyl alcohol particle embolization of dental socket hemorrhages is technically feasible and effective.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2011-010044DOI Listing
July 2012

Evolution of a multidisciplinary cerebrovascular center: lessons learned.

J Neurointerv Surg 2012 Mar 11;4(2):147-51. Epub 2011 May 11.

Cerebrovascular Center, Cleveland Clinic, Cleveland, OH 44195, USA.

The Cerebrovascular Center at the Cleveland Clinic is an integrated, multidisciplinary center comprising vascular neurologists, neurointensivists, physiatrists, open and endovascular neurosurgeons, interventional neurologists and interventional neuroradiologists administered through a single financial center with unified governance and leadership. This report describes the history and evolution of the center from conceptualization to the present, as well as outlining lessons learned in the formation and maturation of the group.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/jnis.2010.004101DOI Listing
March 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.111.613877DOI Listing
July 2011

Reduction of false-negative results in inferior petrosal sinus sampling with simultaneous prolactin and corticotropin measurement.

Endocr Pract 2011 Jan-Feb;17(1):33-40

Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio 44195, USA.

Objective: To investigate the value of prolactin as an independent marker of catheter placement to improve the diagnostic accuracy of inferior petrosal sinus sampling (IPSS) in patients with corticotropin-dependent Cushing syndrome.

Methods: In this retrospective cohort study, we reviewed hospital records of patients who underwent IPSS procedures at the Cleveland Clinic between 1997 and 2009. Serum prolactin and plasma corticotropin levels were measured prospectively in peripheral and inferior petrosal sinus (IPS) samples.

Results: Forty-one patients underwent 42 IPSS procedures at our institution during the study period. Among 35 patients with Cushing disease, 1 patient had erroneous IPSS results: all pre-corticotropin-releasing hormone (CRH) and post-CRH IPS to peripheral (IPS:P) ACTH ratios were less than 2 and less than 3, respectively. Despite radiologic evidence of appropriate IPS catheter placement, concurrent IPS:P prolactin ratios indicated that successful IPS venous sampling was not achieved. A second case with equivocal IPSS results could also be explained by corresponding IPS:P prolactin ratios. During IPSS, all patients with an identifiable ACTH-staining adenoma localizing to 1 side of the pituitary gland (n = 22) who demonstrated absent IPS:P ACTH gradients (<2 before or <3 after CRH administration) on the ipsilateral side of the corticotroph adenoma had corresponding IPS:P prolactin ratios less than 1.3.

Conclusions: Measurement of prolactin during IPSS testing may reduce false-negative results in patients with Cushing disease who do not demonstrate an appropriate central-to-peripheral ACTH gradient. In our series, all false-negative IPS:P ACTH ratios had a corresponding IPS:P prolactin ratio less than 1.3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4158/EP10067.ORDOI Listing
August 2011

Symptomatic delayed reocclusion after initial successful revascularization in acute ischemic stroke.

J Stroke Cerebrovasc Dis 2010 Jan;19(1):36-9

Cerebrovascular Center, Cleveland Clinic Foundation, Ohio 44195, USA.

Background: Endovascular stroke therapy is used for patients with ischemic stroke after failed intravenous thrombolysis or in patients not eligible for thrombolytics. With increasing experience, acute reocclusion has been described and likely worsens clinical outcomes. We assessed the rates and outcomes of delayed symptomatic reocclusion after endovascular therapy for acute ischemic stroke.

Methods: Patients with acute ischemic stroke undergoing endovascular procedures at out institutions from January 2008 to August 2008 were reviewed. In all, 107 consecutive acute stroke interventions were performed. Four patients (3.5%) experienced delayed symptomatic reocclusion detectable by the National Institutes of Health Stroke Scale (NIHSS).

Results: The 4 patients (age 45-79 years) had baseline NIHSS score ranging from 8 to 24. Three had right middle cerebral artery occlusions and one had a left middle cerebral artery occlusion. Successful recanalization (thrombolysis in myocardial infarction score 2-3) occurred in all cases after initial treatment. All patients improved postprocedure (NIHSS score 5-10). Clinical deterioration (NIHSS score 14-22) occurred 12 to 18 hours postprocedure. Successful recanalization was achieved in each patient, with improvement in NIHSS score (range 6-13) but not to a lower level compared with after the initial intervention.

Conclusions: Delayed symptomatic reocclusion after initial endovascular stroke therapy can lead to sudden clinical deterioration and impact outcomes. The entity may be missed as many patients present with large clinical deficits at presentation thus requiring careful assessments of patients treated via endovascular methods.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2009.03.002DOI Listing
January 2010

Mechanical thrombectomy for acute stroke with the alligator retrieval device.

Stroke 2009 Dec 15;40(12):3784-8. Epub 2009 Oct 15.

Section of Cerebrovascular and Endovascular Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OHIO, USA.

Background And Purpose: Recanalization of occluded vessels in acute ischemic stroke is associated with improved outcome. Devices that can quickly and safely remove thrombus and promote recanalization are useful in the management of these patients. The Alligator retrieval device, developed for endovascular foreign body retrieval, may also be useful for thrombus removal.

Methods: Seven patients with acute ischemic stroke (aged 31 to 88 years) who underwent intra-arterial therapy with the Alligator retrieval device at our center are presented.

Results: The Alligator retrieval device was able to retrieve the thrombus in 5 of 7 cases with good to excellent recanalization seen and was unsuccessful in 2 of 7 patients. Complete recanalization was obtained in one of 7 patients and near complete recanalization obtained in 4 of 7 patients. Three of the 7 patients had good outcome at 3 months and 3 of 7 patients died within 30 days of treatment.

Conclusions: The Alligator retrieval device was successfully able to remove thrombus in the majority of cases. It appears to have increased success in proximal occlusions in relatively straight segments. In properly selected cases, it may be a useful device in intra-arterial stroke management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.108.525618DOI Listing
December 2009

Delayed symptomatic coil migration after initially successful balloon-assisted aneurysm coiling: technical case report.

Neurosurgery 2009 Feb;64(2):E391-2; discussion E392

Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona 85013, USA.

Objective: To describe delayed migration of a coil loop after adjunctive balloon remodeling of an anterior communicating artery aneurysm.

Methods: A 56-year-old man with a subarachnoid hemorrhage from a small anterior communicating artery aneurysm underwent successful coil embolization with adjunctive balloon remodeling.

Results: Eight days after the procedure, the patient returned with the acute onset of right lower extremity paralysis. Magnetic resonance imaging demonstrated an acute left anterior cerebral artery territory infarction. Angiography demonstrated that this infarct was secondary to the delayed migration of a coil loop out of the aneurysm and into the left A1 to A2 junction.

Conclusion: Delayed migration of a coil loop after adjunctive balloon remodeling represents a rare but potentially severe complication of this technique.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.NEU.0000338261.78964.C1DOI Listing
February 2009

Revascularization of symptomatic subacute cerebrovascular occlusions with a self-expanding intracranial stent system.

Neurosurgery 2009 Jan;64(1):72-8; discussion 78

Division of Neurosurgery, Royal University Hospital, Saskatoon, Canada.

Objective: In some patients, collateral circulation may preserve the viability of brain parenchyma distal to an intracranial arterial occlusion for hours or days after the presenting event. These patients may be good candidates for revascularization, even when they present outside of the accepted 6-hour time window for stroke intervention.

Methods: Three patients were revascularized with the Wingspan stent system (Boston Scientific/Target, Fremont, CA) after presenting with subacute occlusions of intracranial arteries and progressive ischemic symptoms despite maximal medical therapy. All pre- and postprocedural imaging data and clinical records were reviewed.

Results: Three patients (mean age, 64 years; 2 women, 1 man) presented with symptomatic intracranial occlusions of the internal carotid artery (n = 2) and vertebrobasilar system (n = 1). All 3 patients presented more than 6 hours after symptom onset, and no intravenous or intra-arterial thrombolysis had been instituted. In all cases, despite supportive medical therapy (anticoagulation and antiplatelet therapy and induced hypertension), the patients continued to demonstrate progressive ischemia, both clinically and on diffusion magnetic resonance imaging. All patients were successfully revascularized without periprocedural complications and improved clinically after revascularization.

Conclusion: In selected patients, symptomatic subacute occlusions of intracranial arteries may be revascularized using the Wingspan stent system.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.NEU.0000334049.12472.B7DOI Listing
January 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.NEU.0000335067.53190.A2DOI Listing
July 2008

Stent reconstruction of wide-necked aneurysms across the circle of Willis.

Neurosurgery 2007 Nov;61(5 Suppl 2):249-54; discussion 254-5

Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Cleveland Clinic, Cleveland, Ohio 44195, USA.

Objective: To describe a novel technique for single stent reconstruction of wide-necked aneurysms arising from the circle of Willis.

Methods: Neuroform stents (Boston Scientific/Target, Fremont, CA) were placed across the basilar apex (right P1 to left P1) via the posterior communicating artery in two patients, across the left carotid terminus (left A1 to left M1) via the anterior communicating artery in two patients, and across the anterior communicating artery (left A1 to right A1) in one patient for stent-supported coil embolization.

Results: Five women underwent successful deployment of the Neuroform stent across the circle of Willis to support subsequent coil embolization of a wide-necked cerebral aneurysm. In two patients with subarachnoid hemorrhage, initial dome coiling was performed for short-term protection, and stents were applied across the circle of Willis to support completion of coil embolization during a second session. None of the patients experienced any periprocedural or delayed neurological complications.

Conclusion: Stenting across the circle of Willis represents a novel adjuvant technique to support the coiling of selected wide-necked intracranial aneurysms. This technique is particularly useful for wide-necked terminal aneurysms that incorporate both branches of a bifurcation in a configuration unfavorable for Y-stent reconstruction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.neu.0000303977.04128.3eDOI Listing
November 2007

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.NEU.0000290914.24976.83DOI Listing
September 2007

A 7-year experience with balloon-mounted coronary stents for the treatment of symptomatic vertebrobasilar intracranial atheromatous disease.

Neurosurgery 2007 Aug;61(2):236-42; discussion 242-3

Department of Neuroradiology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

Objective: Balloon-mounted coronary stents (BMCS) have been adapted for use in the intracranial circulation for the treatment of symptomatic intracranial atheromatous disease (ICAD). We performed a retrospective analysis of our 7-year experience with these devices in an attempt to quantify the periprocedural risks and long-term outcomes in patients with symptomatic ICAD of the vertebrobasilar (VB) system treated with BMCS.

Methods: A retrospective review of a prospectively maintained database was performed to determine the neurological and non-neurological periprocedural risks of BMCS treatment of ICAD. Patients were followed with serial transcranial Doppler (TCD) and, in some cases, angiographic imaging. The clinical status was determined based on clinic visits and by telephone interviews when possible.

Results: Over the 6-year period from March 1999 to May 2005, 44 patients (35 men, 9 women; average age, 64.8 yr) with 47 symptomatic atheromatous lesions of the VB system were treated with BMCS. In two patients, the BMSC could not be delivered across the target lesion. Treatment of the remaining 45 lesions was technically successful (95.7%). The periprocedural neurological morbidity and mortality was 26.1% (10 clinically evident strokes, 2 deaths). One additional patient experienced a periprocedural transient ischemic attack (TIA). Two patients died of non-neurological causes within 6 months (4.3%, myocardial infarction and cholecystitis). The average stenosis measured 82.5%, declining to 10.0% stenosis after BMCS. TCD examinations showed a preprocedural velocity of 127.7 cm/second (n = 43; standard deviation, 63.7 cm/s), which declined to 54.0 cm/s immediately after the procedure (n = 42; standard deviation, 22.7 cm/s). In patients with serial TCD evaluations, velocities were typically constant over years of follow-up (six patients with >5 yr of follow-up; average velocity, 52.2 cm/s). Angiographic follow-up was available for 11 patients. Three patients had stent occlusion (all symptomatic with TIAs), one patient had greater than 50% in-stent restenosis (ISR) (symptomatic with TIA) and seven had no significant (<50%) stenosis. The overall ISR/occlusion rate was 12.5% (4 out of 32 lesions with angiographic and/or TCD follow-up > 6 mo). Of the 42 patients who successfully underwent BMCS, clinical follow-up was available for 33 (78.6%, average follow-up period, 43.5 mo), three patients died before any follow-up could be performed, and seven were lost to follow-up. Of the patients with follow-up, five had recurrent vertebrobasilar ischemic symptoms (15%; four TIA, one stroke). Four out of five patients with recurrent symptoms had ISR or occlusion verified on conventional angiography. At the time of the last follow-up examination, seven patients of 44 patients who underwent attempted treatment were dead (modified Rankin Scale [mRS] score, 6); four had an mRS score of 3 to 5, 16 had an mRS score of 1 or 2, and 10 had an mRS score of 0.

Conclusion: Percutaneous transluminal angioplasty and stenting using BMCS for the treatment of symptomatic VB ICAD can be carried out with high rates of technical success and excellent immediate angiographic results. However, the procedure carries with it a very high rate of periprocedural morbidity and mortality. Greater than 50% ISR or stent occlusion occurred in 12.5% of the patients and was associated with recurrent TIAs. In the absence of ISR/occlusion, patients who tolerated the initial procedure did well neurologically and did not typically experience recurrent ischemic symptoms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.NEU.0000255521.42579.31DOI Listing
August 2007

Adjunctive rheolytic thrombectomy for central venous sinus thrombosis: technical case report.

Neurosurgery 2007 Mar;60(3):E577-8; discussioin E578

Department of Neuroradiology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

Objective: Patients with dural sinus thrombosis occasionally present with a malignant clinical course marked by parenchymal hemorrhage accompanied by either a severe neurological deficit or a persistent deterioration on therapeutic levels of antithrombotic medications. This scenario precludes traditional revascularization strategies with direct fibrinolytic infusion because of the risk of exacerbating the preexisting cerebral hemorrhage. In the current series, we describe our experience using the AngioJet (Possis Medical, Minneapolis, MN), a rheolytic mechanical thrombectomy device, in conjunction with systemic heparinization to achieve rapid sinus revascularization without fibrinolytic therapy.

Methods: A retrospective review of a prospectively maintained database identified four patients ranging in age from 28 to 67 years (three women, one man) with cerebral venous thrombosis and rapidly deteriorating levels of consciousness who underwent transfemoral intravenous rheolytic thrombectomy using the AngioJet XMI and/or Xpeedior catheters (Possis Medical). The imaging features, treatment specifications, and disease outcome were reviewed.

Results: All four patients underwent successful mechanical thrombectomy as indicated by restoration of blood flow through the affected sinuses. Three of the four patients demonstrated normalization of angiographic transit time after thrombectomy. In these three patients, rapid neurological improvement ensued. The fourth patient died during the periprocedural period. No procedural complications were encountered.

Conclusion: Systemic heparinization with adjunctive rheolytic thrombectomy (without fibrinolytic therapy) is a safe and effective treatment strategy for selected patients with dural venous sinus thrombosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.NEU.0000255339.26027.68DOI Listing
March 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/01.STR.0000257963.65728.e8DOI Listing
March 2007

Stent-assisted detachable coil embolization of pseudoaneurysms in the coronary circulation.

Catheter Cardiovasc Interv 2006 Sep;68(3):409-15

Department of Cardiovascular Medicine, Section of Interventional Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

Pseudoaneurysms in the coronary circulation are an uncommon occurrence that can develop spontaneously in the setting of atherosclerosis or can develop after catheter-based coronary interventions. The natural history, clinical outcome, and optimal therapy for pseudoaneurysms in the coronary circulation are not clearly established. Recent advances in the techniques and technologies used for endovascular treatment of intracranial aneurysms may be applicable to the management of coronary aneurysms and pseudoaneurysms. We present a case of spontaneous coronary pseudoaneurysm formation after paclitaxel drug-eluting stent implantation and a case of pseudoaneurysm formation in a saphenous vein graft that were both successfully treated with stent-assisted detachable coil embolization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.20879DOI Listing
September 2006

Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms.

Neurosurgery 2006 Aug;59(2):291-300; discussion 291-300

Department of Neuroradiology, Cleveland Clinic, Cleveland, Ohio 44195, USA.

Objective: Intradural pseudoaneurysms have a malignant natural history and can be difficult to treat if parent vessel deconstruction is not feasible. These lesions often involve a long arterial segment and lack a defined saccular component that would safely accommodate the introduction of embolization coils. The current report describes the successful endovascular treatment of these lesions using a strategy of Neuroform stent reconstruction.

Methods: A retrospective review of the prospectively maintained Neuroform databases from our two institutions identified all intracranial aneurysms treated with the Neuroform stent alone, without embolization coils. The clinical charts, procedural data, and angiographic results were reviewed.

Results: Over a 38-month study period (10/02-2/06), 266 aneurysms were treated with the Neuroform stent. Of these, 10 were small "uncoilable" intradural pseudoaneurysms associated with subarachnoid hemorrhage. These lesions were treated using a strategy of endovascular stent reconstruction of the diseased vascular segment with one or more Neuroform stents (without concomitant coil embolization). Seven pseudoaneurysms were treated in the context of acute or subacute subarachnoid hemorrhage, and three were associated with a remote history of subarachnoid hemorrhage. Periprocedural complications occurred in two patients (clinically silent, intraprocedural thromboembolic event successfully treated with intra-arterial abciximab, symptomatic postprocedural stent thrombosis with successful thrombolysis, and excellent neurological recovery). Both complications occurred in patients with ruptured aneurysms and could be attributed to inadequate platelet inhibition at the time of the initial procedure. Follow-up conventional angiographic examinations were available for all 10 patients with pseudoaneurysms (1-18.5 mo; average, 9.0 mo). In nine cases, the aneurysms improved at follow-up, with either complete (n = 5) or near complete (n = 4) resolution. In one case, short-term follow-up (1 mo) demonstrated no significant change. No patient has rehemorrhaged after treatment.

Conclusion: Endovascular Neuroform stent reconstruction represents an optimal strategy for the management of intradural pseudoaneurysms that require a constructive treatment strategy and are too small to accommodate the introduction of embolization coils. Nine out of 10 patients in the current series treated with this strategy demonstrated some degree of endovascular remodeling with either complete (n = 5) or partial (n = 4) angiographic resolution at follow-up. No rehemorrhages were encountered. Adequate antiplatelet therapy, even in the setting of acute subarachnoid hemorrhage, is prerequisite for the avoidance of thromboembolic complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.NEU.0000223650.11954.6CDOI Listing
August 2006

Neuroform in-stent stenosis: incidence, natural history, and treatment strategies.

Neurosurgery 2006 Jul;59(1):34-42; discussion 34-42

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

Objective: Delayed in-stent stenosis is an important and well-characterized complication of angioplasty and stenting for the treatment of intra- and extracranial atheromatous disease. The current series describes the incidence and natural history of in-stent stenosis after the deployment of the Neuroform stent within the cerebrovasculature for the treatment of aneurysms.

Methods: The collaborative Cleveland Clinic Foundation-Barrow Neurological Institute endovascular database was reviewed to identify cases of delayed moderate or severe in-stent stenosis observed during the follow-up of cerebral aneurysms treated with the Neuroform stent. The hospital charts, clinic records, and operative reports for these patients were reviewed.

Results: Of a total of 156 patients with follow-up, nine (5.8%) cases of moderate or severe delayed (>2 mo) in-stent stenosis were identified, including two parent vessel occlusions. In two cases, patients presented 3 months after stent-supported aneurysm embolization with focal neurological symptoms. Both of these patients were treated with angioplasty. One eventually required surgical bypass. Of the seven asymptomatic patients, four demonstrated some degree of spontaneous resolution at follow-up, one progressed to complete occlusion, one is awaiting further follow-up, and one patient died of unrelated causes. Of the nine patients in the series, five were treated with "bioactive" coils (Matrix, Hydrocoil, Cerecyte), three were treated with bare platinum coils, and one was treated with stenting alone. The earliest time interval to diagnosis was 2.5 months and 3 months for asymptomatic and symptomatic patients, respectively. The earliest interval documented for spontaneous resolution was 9 months.

Conclusion: Delayed Neuroform in-stent stenosis, occurring in 5.8% of cases, is not a rare phenomenon. The stenosis can be symptomatic and may require endovascular treatment or surgical bypass. In asymptomatic patients, a strategy of "watchful waiting" may be effective because many patients demonstrate partial or complete resolution at follow-up. The spontaneous resolution of delayed in-stent stenosis has not been previously described. This may be a phenomenon unique to the application of low radial force, self-expanding stents within the nonatheromatous cerebrovasculature.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.NEU.0000219853.56553.71DOI Listing
July 2006

Balloon-in-stent technique for the constructive endovascular treatment of "ultra-wide necked" circumferential aneurysms.

Neurosurgery 2005 Dec;57(6):1218-27; discussion 1218-27

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

Introduction: Circumferential aneurysms, which incorporate >180 degrees of the circumference of the parent vessel, present a unique therapeutic challenge, particularly in circumstances in which a deconstructive treatment strategy is not feasible. We detail a novel technique for endovascular parent vessel reconstruction with aneurysm embolization.

Methods: We performed a retrospective review of the prospectively maintained databases of our two institutions to identify cases in which a balloon-in-stent technique had been used to treat circumferential aneurysms. During the first stage of this technique, a stent (Neuroform [Boston Scientific, Natick, MA], Multilink Vision [Guidant, Indianapolis, IN], or Bx Velocity [Cordis, New Brunswick, NJ]) is placed across the neck of the aneurysm to achieve parent vessel reconstruction. During the second stage, aneurysm coil embolization is performed with a compliant temporary occlusion balloon (Sentry [Boston Scientific, Natick, MA] or Hyperglide [Microtherapeutics, Irvine, CA]) placed within the stent to unambiguously demarcate and protect the parent vessel. In some cases, during the course of the embolization, coils project over and obscure the parent vessel in both working views. Before each coil detachment, the protection balloon is deflated under blank fluoroscopic roadmap visualization. The absence of shifting of any portion of the coil mass during balloon deflation indicates that the introduced coil is external to the stent-reconstructed parent vessel (i.e., within the aneurysm) and can be detached. This process is repeated until satisfactory aneurysm embolization is achieved. After embolization, the balloon catheter may be exchanged for a stent delivery system to facilitate the placement of a second stent.

Results: Seven patients underwent balloon-in-stent-assisted embolization over a 15-month period. Three were performed for internal carotid aneurysms, three for basilar trunk or basilar apex aneurysms, and one for a dissecting/fusiform V4 segment vertebral artery aneurysm. In three cases, the presence of the inflated balloon facilitated the manipulation of the image intensifier into a position which produced a "down-the-barrel" view of the parent vessel. In the four additional cases, for anatomic reasons, this view could not be achieved and coil mass projected over the reconstructed parent vessel in both views. Partial aneurysm occlusion (75-90%), was achieved in five cases, and near complete (>95%) occlusion was achieved in two cases. Complications included two significant retroperitoneal hematomas and two brainstem infarcts, both of which resulted in hemisensory symptoms.

Conclusion: The balloon-in-stent technique provides a practical and safe treatment strategy for the management of circumferential aneurysms that are not amenable to deconstructive embolization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1227/01.neu.0000186036.35823.10DOI Listing
December 2005
-->