Primary Angioplasty without Stenting for Symptomatic, High-Grade Intracranial Stenosis with Poor Circulation

Fellows’ Journal Club

Thirty-five patients with high-grade, symptomatic intracranial stenosis and poor antegrade flow, treated with intracranial angioplasty without stent placement from January 2010 to December 2016, were retrospectively reviewed. The main outcomes included the changes in antegrade flow and residual stenosis and any stroke or death within 1 month. The average preprocedure stenosis was 88%. The immediate, average postprocedure stenosis rate was 25%, and the average postprocedure stenosis rate at last angiographic follow-up was 35%. The primary end point of major stroke or death at 30 days was observed in 1 patient (1/35, 2.9%), and no patient had intraprocedural complications. The authors conclude that primary balloon angioplasty was an effective treatment option for symptomatic intracranial stenosis with a high risk of stroke.

Portal Hypertension: Imaging, Diagnosis, and Endovascular Management, 3rd Edition

Saad EA. Portal Hypertension: Imaging, Diagnosis and Endovascular Management,  3rd Ed. Theime; 2017; 344 pp; 242 ill; $149.99

Portal Hypertension Imaging, Diagnosis and Endovascular Management--SaadPortal hypertension is an end-stage manifestation of liver cirrhosis with numerous, potentially life threatening and life-altering manifestations. Radiology, and specifically interventional radiology, play a central role in its diagnosis and management. Procedures range from as simple and mundane as paracentesis to as complex and exotic as a percutaneous mesocaval shunt. This book, Portal Hypertension: Imaging, Diagnosis and Endovascular Management. 3rd Edition, provides a 360-degree exploration of portal hypertension geared towards the interventional radiologist.

This book is divided into four sections and the first is on the pathology/pathophysiology of cirrhosis and portal hypertension. The second section provides an overview of medical, endoscopic and surgical management of portal hypertension. Section 3, the meat of the book, contains 17 of the 33 chapters. It has detailed chapters on all aspects of Transjugular Intrahepatic Portal-Systemic Shunt (TIPS) including patient selection, physiologic effects of TIPS, and expected clinical results of TIPS. The final section is on the balloon-occluded retrograde transvenous obliteration of varices and its variations.

This book is detailed, comprehensive, well illustrated (>250 figures), and well organized. The authorship is a veritable “Who’s Who” of interventional radiologists with many “household names” in IR including past presidents of the Society of Interventional Radiology (SIR) and Gold Medalists in SIR. The most illustrious author, underscoring the high quality of authorship within this book is the late Dr. Josef Rösch. Amongst Dr. Rösch’s many contributions to the field of medicine and interventional radiology, was a discovery he made in 1969, when he accidentally punctured the portal vein while performing a transjugular cholangiogram. While others without his brilliance and creativity would have seen accidental entry into the portal vein as simply a mistake, he realized that this would allow …

Endovascular Treatment of Dural Arteriovenous Fistulas Using Transarterial Liquid Embolization in Combination with Transvenous Balloon-Assisted Protection of the Venous Sinus

Fellows’ Journal Club

The authors report their single-center experience in 22 patients with dural arteriovenous fistulas who were treated with transarterial liquid embolization in combination with transvenous balloon-assisted protection of the affected venous sinus. All patients were symptomatic, of whom 81.8% presented with tinnitus; 9.1%, with ocular symptoms; and 9.1%, with headache. Most fistulas were located at the transverse and/or sigmoid sinus. The most frequent fistula type was Cognard IIa+b (40.9%), followed by Cognard I (31.8%) and Cognard IIa (27.3%)/Borden I (59.1%), and Borden II (40.9%). The affected sinus could be preserved in all except for 1 patient in whom it was sacrificed in a second treatment procedure by coil embolization. The overall complete occlusion rate was 86.4%. The overall complication rate was 20%, with transient and permanent morbidity and mortality of 8%, 0%, and 0%, respectively. They conclude that transarterial liquid embolization of dural arteriovenous fistulas in combination with transvenous balloon-assisted protection of the venous sinus is feasible and safe.

Multicentric Experience in Distal-to-Proximal Revascularization of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection

Fellows’ Journal Club

Prospectively managed stroke data bases from 2 separate centers were retrospectively studied between 2009 and 2014 for records of tandem occlusions related to internal carotid dissection. The first step in the revascularization procedure was intracranial thrombectomy. Then, cervical carotid stent placement was performed depending on the functionality of the circle of Willis and the persistence of residual cervical ICA occlusion, severe stenosis, or thrombus apposition. Efficiency, complications, and radiologic and clinical outcomes were recorded. Thirty-four patients presenting with tandem occlusion stroke secondary to internal carotid dissection were treated during the study period. The mean age was 52.5 years, the mean initial NIHSS score was 17, and the mean delay between onset and groin puncture was 3.58 hours. Recanalization of TICI 2b/3 was obtained in 21 cases (62%). Fifteen patients underwent cervical carotid stent placement. There was no recurrence of ipsilateral stroke in the nonstented subgroup. The authors conclude that endovascular treatment of internal carotid dissection-related tandem occlusion stroke using the distal-to-proximal recanalization strategy appears to be feasible, with low complication rates and considerable rates of successful recanalization.

Value of Quantitative Collateral Scoring on CT Angiography in Patients with Acute Ischemic Stroke

Fellows’ Journal Club

From the MR CLEAN data base, all baseline thin-slice CTA images of patients with acute ischemic stroke with intracranial large-vessel occlusion were retrospectively collected. The quantitative collateral score was calculated as the ratio of the vascular appearance of both hemispheres and was compared with the visual collateral score. Primary outcomes were 90-day mRS score and follow-up infarct volume. A total of 442 patients were included. The quantitative collateral score strongly correlated with the visual collateral score and was an independent predictor of mRS and follow-up infarct volume per 10% increase. The quantitative collateral score showed areas under the curve of 0.71 and 0.69 for predicting functional independence (mRS 0-2) and follow-up infarct volume of greater than 90 mL, respectively. The authors conclude that automated quantitative collateral scoring in patients with acute ischemic stroke is a reliable and user-independent measure of the collateral capacity on baseline CTA and has the potential to augment the triage of patients with acute stroke for endovascular therapy.

European Multicenter Study for the Evaluation of a Dual-Layer Flow-Diverting Stent for Treatment of Wide-Neck Intracranial Aneurysms: The European Flow-Redirection Intraluminal Device Study

Editor’s Choice

Consecutive patients with intracranial aneurysms treated with the FRED between February 2012 and March 2015 were retrospectively reviewed. Complications and adverse events, transient and permanent morbidity, mortality, and occlusion rates were evaluated. A total of 579 aneurysms in 531 patients were treated with the FRED. Seven percent of patients were treated in the acute phase of aneurysm rupture. The median aneurysm size was 7.6 mm and the median neck size 4.5 mm. There was progressive occlusion witnessed with time, with complete occlusion in 18 (20%) aneurysms followed for up to 90 days, 141 (82.5%) for 180 days, 116 (91.3%) for 1 year, and 122 (95.3%) aneurysms followed for more than 1 year. This retrospective study in real-world patients demonstrated the safety and efficacy of the FRED for the treatment of intracranial aneurysms.

Accuracy of CT Angiography for Differentiating Pseudo-Occlusion from True Occlusion or High-Grade Stenosis of the Extracranial ICA in Acute Ischemic Stroke: A Retrospective MR CLEAN Substudy

Fellows’ Journal Club

All patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) with an apparent ICA occlusion on CTA and available DSA images were included. Two independent observers classified CTA images as atherosclerotic cause (occlusion/high-grade stenosis), dissection, or suspected pseudo-occlusion. Pseudo-occlusion was suspected if CTA showed a gradual contrast decline located above the level of the carotid bulb, especially in the presence of an occludedintracranial ICA bifurcation (T-occlusion). In 108 of 476 patients (23%), CTA showed an apparent extracranial carotid occlusion. DSA was available in 46 of these cases, showing an atherosclerotic cause in 13 (28%), dissection in 16 (35%), and pseudo-occlusion in 17 (37%). The sensitivity for detecting pseudo-occlusion on CTA was 82% for both observers. The authors conclude that on CTA, extracranial ICA pseudo-occlusions can be differentiated from true carotid occlusions.

Endovascular Thrombectomy in Wake-Up Stroke and Stroke with Unknown Symptom Onset

Fellows’ Journal Club

The authors evaluated 1073 patients with anterior circulation stroke undergoing mechanical thrombectomy between 2010 and 2016. Patients with wake-up stroke and daytime-unwitnessed stroke were compared with controls receiving mechanical thrombectomy as the standard of care. There was no significant difference in good functional outcome between patients with wake-up stroke and controls. Outcome in patients with daytime-unwitnessed stroke was inferior compared with controls. Groups did not differ in all-cause mortality at day 90 and the rate of symptomatic intracranial hemorrhage. They conclude that mechanical thrombectomy in selected patients with wake-up stroke allows a good functional outcome comparable with that of controls.

Feasibility of Permanent Stenting with Solitaire FR as a Rescue Treatment for the Reperfusion of Acute Intracranial Artery Occlusion

Fellows’ Journal Club

From January 2011 through January 2016, among 2979 patients with acute ischemic stroke, the authors identified 27 patients who underwent permanent stent placement (13 patients with the Solitaire FR and 14 patients with other self-expanding stents). The postprocedural modified TICI grade and angiographic and clinical outcomes were assessed. Stent placement was successful in all cases. Modified TICI 2b=3 reperfusion was noted in 84.6% of the Solitaire group and in 78.6% of the other stent group. They conclude that permanent stent placement with the Solitaire FR compared with other self-expanding stents appears to be feasible and safe as a rescue tool for refractory intra-arterial therapy.

Two-Center Experience in the Endovascular Treatment of Ruptured and Unruptured Intracranial Aneurysms Using the WEB Device: A Retrospective Analysis

Fellows’ Journal Club

The authors performed a retrospective analysis of all ruptured and unruptured aneurysms treated with a WEB device between August 2014 and February 2017. Primary outcome measures included the feasibility of implantation and the angiographic outcome. Secondary outcome measures included the clinical outcome at discharge and procedural complications. One hundred two aneurysms in 101 patients, including 37 (36.3%) ruptured aneurysms, were treated with the WEB device. Implantation was successful in 98 (96.1%) aneurysms. Additional devices (stents/coils) were necessary in 15.3% (15/98) of aneurysms. Delayed aneurysm ruptures have not been observed during the follow-up period to date. They conclude that the WEB device offers a safe and effective treatment option for broad-based intracranial aneurysms without the need for dual antiplatelet therapy.