BACKGROUND:Utilization of the Pipeline embolization device (PED) to treat distal carotid circulation aneurysms has not been well studied.
OBJECTIVE:To report the collective experience of using PED to ...treat distal anterior circulation aneurysms.
METHODS:We retrospectively reviewed clinical and radiographic records of all patients who underwent Pipeline embolization of distal anterior circulation aneurysms at 10 US neurosurgical centers between 2011 and 2013.
RESULTS:Twenty-eight patients (mean age 51.7 years; 18 women) with 28 aneurysms were included in the analyses. Fifteen aneurysms were fusiform, 5 dissecting, and 8 saccular. Average aneurysm size was 12.3 mm; 7 were giant. Twenty aneurysms were located along the middle cerebral artery, 6 along the anterior cerebral artery, and 2 along the anterior communicating artery. PED deployment was successful in 27 patients, with coils utilized in 6 cases. Clinical follow-up was available for an average of 10.7 months (range 3-26). Twenty-seven patients had follow-up neurovascular imaging21 aneurysms had complete occlusion, 4 had residual neck filling, and 2 had residual dome filling. Periprocedural complications (<30 days) occurred in 3 patients (10.7%), including 1 case of device failure resulting in stroke. Outcomes were good (modified Rankin Scale score 0 to 2) in 27 patients (96.4%) and fair (modified Rankin Scale 3) in 1.
CONCLUSION:PED can be utilized in the treatment of distal anterior circulation aneurysms with difficult anatomy for conventional surgical or endovascular techniques. Larger-scale studies with long-term follow-up are needed to further elucidate the durability of PED treatment and its effect on perforator-rich vascular segments.
ABBREVIATIONS:ACA, anterior cerebral arteryAcomA, anterior communicating arteryDSA, digital subtraction angiographyMCA, middle cerebral arterymRS, modified Rankin scalePED, Pipeline embolization device
Abstract
BACKGROUND:
The Enterprise Vascular Reconstruction Device and Delivery System (Cordis; the Enterprise stent) was approved for use in conjunction with coiling of wide-necked aneurysms in ...2007. No published long-term aneurysm occlusion or complication data exist for the Enterprise system.
OBJECTIVE:
We compiled data on consecutive patients treated with Enterprise stent-assisted coiling of aneurysms from 9 high-volume neurointerventional centers.
METHODS:
A 9 center registry was created to evaluate large volume data on the delayed safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution prior to May 2009.
RESULTS:
Two-hundred twenty-nine patients with 229 aneurysms, 32 of which were ruptured aneurysms, were included in the study. Mean clinical and angiographic follow-up was 619.6 ± 26.4 days and 655.7 ± 25.2 days, respectively. Mean aneurysm size was 9.2 ± 0.4 mm. Fifty-nine percent of patients demonstrated 100% coil obliteration and 81% had 90% or higher occlusion at last follow-up angiography. A total of 19 patients (8.3%) underwent retreatment of their aneurysms during the follow-up period. Angiographic in-stent stenosis was seen in 3.4% and thromboembolic events occurred in 4.4%. Overall, 90% of patients who underwent Enterprise-assisted coiling had a modified Rankin Scale score of 2 or less at last follow-up. A poor modified Rankin Scale score was strongly associated with rupture status (P < .001).
CONCLUSION:
Although this study is limited by its retrospective nature, the Enterprise stent system appears to be an effective, safe, and durable treatment for intracranial aneurysms when used in conjunction with coiling.
Isolated traumatic subarachnoid hemorrhage (tSAH) is a common finding in mild traumatic brain injury that often results in transfer to a tertiary center. Patients prescribed blood-thinning ...medications (BTs) are believed to be at higher risk of clinical or radiographic worsening.
To compare the rates of radiographic progression and need for neurosurgical intervention in patients with tSAH who are on anticoagulation (AC) and antiplatelet (AP) therapies with those who are not.
Analysis using a retrospective cohort design identified patients older than 18 years with isolated tSAH and a Glasgow Coma Scale of 15 on admission. Clinical information including use of BTs, administration of reversal agents, radiographic progression, and need for neurosurgical intervention was collected. Patients on BTs were divided into AP, AC, and AP/AC groups based on drug type.
Three hundred eighty-four patients were included with 203 in the non-BT group and 181 in the BT group. Overall, 2.1% had worsening scans, and none required operative intervention. There was no difference in radiographic worsening between the non-BT and BT groups (2.4% vs 1.6%; P = 1.00). Crosswise comparison revealed no difference between the non-BT group and each BT subtype (AP, AP/AC, or AC). The non-BT group was more likely to have radiographic improvement than the BT group (45.8% vs 30.9%; P = .002).
Neurologically intact patients on BTs with isolated tSAH are not at increased risk of radiographic progression or neurosurgical intervention. The presence of BTs should not influence management decisions for increased surveillance.
INTRODUCTION: While endovascular coiling has been shown to be a safe treatment option for intracranial aneurysms, there remains concern regarding increased recurrence and retreatment rates. ...Preliminary studies evaluating hydrogel coated coils have demonstrated decreased recurrence rates compared to bare metal coils.
METHODS: A retrospective chart review was done on all patients with anterior communicating artery aneurysms (ACoAAs) treated with endovascular coiling between 2014 and 2018. Treatment groups were divided into hydrogel coated coils or bare metal coils. Patients were categorized into the hydrogel group when ≥ 70% of the coil length was hydrogel coated.
RESULTS : Eighty-four ACoAAs were treated with coil embolization between 2014 and 2018. Postoperative imaging was available for 68 patients. Twenty-six patients were categorized into the hydrogel treatment group. Aneurysm recurrence was seen in 7.7% (2/26) of patients treated with hydrogel coated coils compared to 33.3% (14/42) of those treated with bare metal coils (P = 0.03). Subanalysis of patients with ruptured aneurysms revealed decreased recurrence rates in patients treated with hydrogel coated coils at 5.9% (1/17) compared to patients treated with bare metal coils at 39.4% (13/33) (P = 0.01).
CONCLUSIONS: Hydrogel-coated coils may reduce recurrence rates in the treatment of both ruptured and unruptured ACoAAs.
Visual misperceptions as a result of neurosurgical disorders are well documented. Alice in Wonderland syndrome (AWS) typically is reported in neurologic and psychiatric disorders. We present a ...patient who developed symptoms of AWS postoperatively.
A 48-year-old man presented in shunt failure, attributed to a proximal catheter occlusion. Operative revision with replacement of the proximal catheter was performed without incident. Postoperatively, he complained of visual disturbances, including the perception that people had small heads on full-sized bodies. Symptoms resolved postoperatively. The patient’s symptoms were diagnosed as a transient episode of AWS. This was attributed to manipulation of the parieto-occipital cortex during the revision. The local inflammatory response from manipulation of that area is thought to have caused our patient’s symptoms.
Visual disturbances caused by lesions along the optic radiations are common findings for neurosurgery patients, although AWS after surgical intervention has not been reported previously.
Introduction
Rapid initiation of mechanical thrombectomy (MT) for the treatment of large-vessel occlusion (LVO) critically improves patient outcomes. Artificial intelligence algorithms aid in the ...identification of LVOs and improve door to puncture times as well as patient transfer times.
Objectives
We aimed to determine whether the implementation of an LVO detection algorithm that provides immediate active notification to the thrombectomy team provider's cell phone would improve ischemic stroke workflow at our institution and aid in patient transfer from outlying hospitals when compared to our prior system of passive computed tomography perfusion software analysis and radiologist interpretation and notification.
Methods
A retrospective review of our institutional thrombectomy registry was performed for all patients who underwent MT between January 2020 and March 2022. Demographic, radiographic, and stroke workflow metrics and notification times were collected. Transfer times and stroke metrics were compared pre- and post-implementation of the Viz.ai (Viz.ai, San Francisco, California, USA) smartphone application.
Results
Two hundred sixty-two patients underwent MT during the study period. Door-to-puncture time decreased 15 min ( p = 0.009) after the implementation of Viz.ai at our Comprehensive Stroke Center. Transfer time from outside hospitals that implemented Viz.ai was reduced by 37 min ( p = 0.04). There was no significant change in transfer time over the same time period in outlying hospitals that did not implement the Viz.ai software.
Conclusion
Active notification of the neurosurgical team significantly reduces patient transfer time and initiation of MT.
Study Objectives
The optimal antiplatelet therapy for emergent neuroendovascular stenting is uncertain. Cangrelor is an intravenous P2Y12 inhibitor that is an attractive option due its favorable ...pharmacokinetic profile and ease of measurability but optimal dosing remains unclear. The primary objective of this study is to characterize the dose response of low dose cangrelor (<2 mcg/kg/min) with the utilization of platelet function testing (PFT).
Design
A retrospective review of all patients treated with cangrelor for either procedural stenting or bridging was conducted between January 1st, 2019 and October 31st, 2020. Seventy‐two patients met inclusion criteria. An in‐depth analysis of dose response to low dose cangrelor based on PFT was performed.
Patients
Neuroendovascular patients treated with cangrelor.
Setting
Albany Medical Center Hospital.
Intervention and Main Results
Patients who underwent procedural stenting were given a bolus of 5 mcg/kg and an initial infusion rate of either 0.75 mcg/kg/min or 1 mcg/kg/min. Patients who were bridged with cangrelor were administered an initial infusion rate of 0.75 mcg/kg/min or 1 mcg/kg/min. Twelve patient’s doses were titrated to achieve a platelet reactivity unit (PRU) between 50–150; three patient’s doses were titrated multiple times. Based on initial PFT results, utilizing the 1 mcg/kg/min maintenance dose resulted in more patients being in the acceptable (10–180) and desired (50–150) PRU range than the 0.75 mcg/kg/min dose (47% vs 56% and 70% vs 80%, respectively). Final recorded PRU results showed that 64% of patients had PRUs in the optimal range (50–150) and 88% of patients had PRUs in the desire range (10–180).
Conclusions
Utilizing low doses of cangrelor with platelet function testing is an option during emergent neuroendovascular stenting and bridging. Cangrelor demonstrates significant variability in response at low doses and exhibits a dose response relationship when PFT is utilized.
The LVIS stent system (LVIS and LVIS Junior) is a self-expanding, retrievable, microstent system indicated for the treatment of wide-necked cerebral aneurysms (WNAs). The present pivotal study was ...performed to evaluate the safety and effectiveness of this device.
The US LVIS pivotal trial was a prospective, multicenter, single-arm, interventional study conducted at 21 US centers. The study enrolled 153 adults with WNAs of the anterior and posterior circulations. The study was conducted under good clinical practices and included independent adjudication of all adverse events. The primary effectiveness endpoint was defined as successful aneurysm treatment with the LVIS System as evidenced by complete (100%) aneurysm occlusion at 12 months on conventional angiography without retreatment and without significant (≥50%) stenosis of the treated artery at 12 months as determined by an independent core laboratory. The primary safety endpoint was defined as the rate of stroke or death within 30 days, or ipsilateral stroke or neurologic death with 12 months.
One hundred and fifty-three patients enrolled at 21 investigational sites underwent attempted LVIS-assisted coil embolization. The mean age was 58.3±10.5 years and the majority of the participants (110/153, 71.9%) were female. Fifty-seven aneurysms (57/153, 37.3%) arose from the anterior cerebral artery, 43 (43/153, 28.1%) from the internal carotid artery, 17 (17/153, 11.1%) from the middle cerebral artery, 27 (27/153, 17.6%) from the basilar artery, six (6/153,3.9 %) from the PCA, and two from the vertebral artery. A single aneurysm arose from the superior cerebellar artery. The mean aneurysm dome height was 6.0±2.2 mm and mean width 5.5±2.3 mm. Mean neck width was 4.2±1.4 mm. A total of 22 participants presented for re-treatment of a previously ruptured (>30 days prior to treatment) target aneurysm. The primary effectiveness endpoint was observed in 70.6% (108/153) in the intent to treat population (ITT). Of the evaluable participants with follow-up 12-month angiography, 79.1 % (110/139) demonstrated complete occlusion- 92.1% (128/139) in this population demonstrated ≥95% occlusion and 95% demonstrated ≥90% occlusion (132/139). Eight participants (5.2%, 8/153) had at least one primary safety event in the ITT population.
The LVIS stent system allows safe and highly effective coil embolization of WNAs.
NCT01793792.
Background
Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is ...an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting.
Methods
A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria.
Results
All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients’ doses were adjusted with subsequent PRUs in or near the goal range of 50–150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred.
Discussion
Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability.
Conclusion
Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk.
PDF
