Interventional

Endovascular Therapy of M2 Occlusion in IMS III: Role of M2 Segment Definition and Location on Clinical and Revascularization Outcomes

Fellows’ Journal Club

The authors reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1–M2 segment anatomic features. AnmRS 0–2 outcome was associated with reperfusion for M2 trunk (n = 9) or M2 division (n = 42) occlusions, but not for M2 branch occlusions (n = 28). Of the 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0–2 at 90 days, including 46.6% with modified TICI 2–3 reperfusion compared with 26.1% with modified TICI 0–1 reperfusion. They conclude that mRS 0–2 at 90 days was dependent on reperfusion for M2 trunk but not for M2 branch occlusions in IMS III.

Abstract

Figure 1 from paper
A, Right M1 trunk gives rise to the ATA with the posterior temporal branch filling on microcatheter injection. B, Lateral view baseline common carotid arteriogram confirms mid- and posterior temporal lobe cortical supply from the patent posterior temporal artery.

BACKGROUND AND PURPOSE

Uncertainty persists regarding the safety and efficacy of endovascular therapy of M2 occlusions following IV tPA. We reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1-M2 segment anatomic features.

MATERIALS AND METHODS

Perfusion of any M2 branch distinguished M2-versus-M1 occlusion. Prespecified modified TICI and arterial occlusive lesion revascularization and clinical mRS 0–2 end points at 90 days for endovascular therapy–treated M2 occlusions were analyzed. Post hoc analyses of the relationship of outcomes to multiple baseline angiographic M2 and M1 subgroup characteristics were performed.

RESULTS

Of 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0–2 at 90 days, including 46.6% with modified TICI 2–3 reperfusion compared with 26.1% with modified TICI 0–1 reperfusion (risk

Emergent Endovascular Management of Long-Segment and Flow-Limiting Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents

Editor’s Choice

The authors investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting in 15 patients. They specifically evaluated long-segment carotid dissections requiring stent reconstruction with multiple tandem stents (≥ 3 stents) and presenting with acute (<12 hours) ischemic stroke symptoms (NIHSS score, ≥ 4). Carotid stent reconstruction was successful in all patients with no residual stenosis or flow limitation. Nine patients (60%) harbored intracranial occlusions, and 6 patients (40%) required intra-arterial thrombolysis/thrombectomy, achieving 100% TICI 2b–3 reperfusion. They conclude that emergent stent reconstruction of long-segment and flow-limiting carotid dissections in acute ischemic stroke intervention is safe and effective, with favorable clinical outcomes.

Yield of Repeat 3D Angiography in Patients with Aneurysmal-Type Subarachnoid Hemorrhage

Fellows’ Journal Club

The purpose of this study was to evaluate the yield of repeat 3D rotational angiography in patients with aneurysmal-type SAH with negative initial 3D rotational angiography findings. Between March 2013 andJanuary 2016, 292 patients with SAH and an aneurysmal bleeding pattern were admitted, with 30 having initial negative 3D rotational angiography findings within 24 hours. These patients underwent a second 3D rotational angiography after 7–10 days. In 8/30 patients (over 26%) with initial negative 3D rotational angiography findings, a ruptured aneurysm wasfound on repeat 3D rotational angiography. The investigators conclude that repeat 3D rotational angiography is mandatory in patients with initial 3D rotational angiography findings negative for aneurysmal-type SAH.

Abstract

Figure 2 from paper
A 62-year-old woman with initial negative findings on 3DRA. A, 3DRA within 24 hours after SAH shows no aneurysm. B, Repeat 3DRA after 10 days shows an 8-mm supraclinoid internal artery dissecting aneurysm.

BACKGROUND AND PURPOSE

Aneurysmal-type subarachnoid hemorrhage is a serious disease with high morbidity and mortality. When no aneurysm is found, the patient remains at risk for rebleeding. Negative findings for SAH on angiography range from 2% to 24%. Most previous studies were based on conventional 2D imaging. 3D rotational angiography depicts more aneurysms than 2D angiography. The purpose of this study was to evaluate the yield of repeat 3D rotational angiography in patients with aneurysmal-type SAH with negative initial 3D rotational angiography findings and to classify the initial occult aneurysms.

MATERIALS AND METHODS

Between March 2013 and January 2016, 292 patients with SAH and an aneurysmal bleeding pattern were admitted. Of these 292 patients, 30 (10.3%; 95% CI, 7.3%–14.3%) had initial negative 3D rotational angiography findings within 24 hours. These patients underwent a second 3D rotational angiography after 7–10 days.

RESULTS

In 8 of 30 patients (26.7%; 95% CI, 14.0%–44.7%) with initial negative 3D

Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Lower NIHSS Scores: Recanalization Rates, Periprocedural Complications, and Clinical Outcome

Editor’s Choice

This is a retrospective analysis of 484 patients in a prospectively collected stroke data base. The inclusion criteria were anterior circulation ischemic stroke treated with mechanical thrombectomy at a single institution between September 2010 and October 2015 with an NIHSS score of ≤8. The purpose was to assess the clinical and interventional data in patients treated with mechanical thrombectomy in case of ischemic stroke with mild-to-moderate symptoms (n = 33). Recanalization (TICI 2b–3) was achieved in 26 (78.7%) patients. Two cases of symptomatic intracranial hemorrhage occurred. Favorable (mRS 0–2) and moderate (mRS 0–3) clinical 90-day outcome was achieved in 63.6% and 90.9% of patients, respectively. The authors conclude that the clinical outcome of patients undergoing mechanical thrombectomy for acute ischemic mild stroke due to large-vessel occlusion is predominately favorable, even in a prolonged time window.

Flow Diversion for Ophthalmic Artery Aneurysms

Fellows’ Journal Club

This is a retrospective review of 48 patients with 50 carotid-ophthalmic aneurysms in which 44 patients with 46 aneurysms were treated with flow diversion from June 2009 to June 2015. There were no permanent adverse visual outcomes. There was 1 death due to late intraparenchymal hemorrhage (2.2%). Six-month angiography showed complete occlusion in 24 of 37 patients (64.9%), and 3-year angiography results showed occlusion in 24 of 25 patients (96%).

SUMMARY

Figure 1 from paper
This 42-year-old woman underwent treatment with 3 PEDs for symptomatic left cavernous and ophthalmic segment aneurysms (shown in 3D rotation angiography, A). Immediate postdeployment early arterial lateral angiography shows both aneurysms filling (B), while late arterial phase shows contrast stasis in both aneurysms (C). After 6 months (D), 1 year (E), and 3 years (F), a lateral early arterial phase angiogram shows persistent ophthalmic aneurysm filling (black arrows), persistent ophthalmic artery filling, and a partially obliterated cavernous aneurysm with persistent filling through the posterior portion of the aneurysm. Because the aneurysm was nearly completely occluded at 3 years, a 5-year follow-up MRA was recommended for further follow-up.

Endovascular treatments of ophthalmic segment aneurysms are commonly used but visual outcomes remain a concern. We performed a retrospective review of patients with carotid-ophthalmic aneurysms treated with flow diversion from June 2009 to June 2015. The following outcomes were studied through chart review: visual outcomes, complications, postoperative stroke and intraparenchymal hemorrhage, and clinical outcomes. Angiographic outcomes were studied with angiography and MRA at 6 months, 1 year, and 3 years. We evaluated 50 carotid-ophthalmic aneurysms in 48 patients, among whom 44 patients with 46 aneurysms underwent treatment. The mean clinical follow-up was 29 ± 22 months (range, 0–65 months). There were no permanent adverse visual outcomes. There was 1 death because of late intraparenchymal hemorrhage (2.2%). Six-month angiography showed

Ocular Signs Caused by Dural Arteriovenous Fistula without Involvement of the Cavernous Sinus: A Case Series with Review of the Literature

Editor’s Choice

Ocular signs are unusual in the presentation of cranial dural arteriovenous fistulas in locations other than the cavernous sinus. Between 2000–2015, 13 patients met the inclusion criteria for this retrospective analysis. The most common signs were chemosis (61.5%), loss of visual acuity (38.5%), exophthalmia (38.5%), and ocular hypertension (7.7%). Dural arteriovenous fistulas presenting with ocular signs were classified into 4 types due to their pathologic mechanism (local venous reflux into the superior ophthalmic vein, massive venous engorgement of the cerebrum responsible for intracranial hypertension, compression of an oculomotor nerve by a venous dilation, or intraorbital fistula with drainage into the superior ophthalmic vein).

Risk Factors for Ischemic Complications following Pipeline Embolization Device Treatment of Intracranial Aneurysms: Results from the IntrePED Study

Editor’s Choice

This is a retrospective subanalysis of the IntrePED study, which has beenpreviously published (AJNR Am J Neuroradiol 2015;36:108–15).Seven hundred ninety-three patients with 906 treated aneurysms were enrolled. Thirty-six (4.5%) patients had postoperative acute ischemic stroke, 21 of which occurred within 1 week of the procedure. There was no difference in the rate of acute stroke between the anterior and posterior circulations. Stroke rate was 3% in patients with 1 PED, and 7% in those with 2 PEDs. With multivariate analysis, the only variable independently associated with postoperative stroke was treatment of fusiform aneurysms. Among the patients with stroke, 10 (27.0%) died and 26 (73.0%) had major neurologic morbidity. The authors conclude that acute ischemic stroke following treatment of intracranial aneurysms with the PED is an uncommon but devastating complication, with 100% of patients having major morbidity or mortality.

WEB Treatment of Ruptured Intracranial Aneurysms

Fellows’ Journal Club

This observational cohort study evaluated 32 patients with 32 acutely ruptured aneurysms endovascularly treated with the Woven EndoBridge (WEB) device. The mean aneurysm size was 4.9 mm, with 14 less than or equal to 4 mm, and most had a wide neck. All aneurysms were adequately occluded, and there were no procedural ruptures or complications related to the WEB device. No adjunctive stents or balloons were needed. Seven patients with poor clinical grade died during hospital admission due to the sequelae of their subarachnoid hemorrhage. The authors conclude that WEB treatment of small ruptured aneurysms was safe and effective without the need for anticoagulation, adjunctive stents, or balloons.

Abstract

Figure 3 from paper
A 57-year-old woman with a ruptured anterior communicating artery aneurysm. A, 3D angiogram shows a small anterior communicating artery aneurysm. Note the spasm in the left A1. B, Measurement of the height (3.9 mm) and neck width (2.3 mm). C, Angiogram directly after placement of a 4-mm WEB-SLS. Note some opacification inside the WEB. D, Angiogram at 3 months demonstrates complete occlusion of the aneurysm.

BACKGROUND AND PURPOSE

The Woven EndoBridge (WEB) device was recently introduced for intrasaccular treatment of wide-neck aneurysms without the need for adjunctive support. We present our first experience in using the WEB for small ruptured aneurysms.

MATERIALS AND METHODS

During 11 months, 32 of 71 (45%) endovascularly treated acutely ruptured aneurysms were treated with the WEB. The patients were 12 men and 20 women, with a mean age of 61 years (range, 34–84 years). The mean aneurysm size was 4.9 mm, and 14 were ≤4 mm. Of 32 aneurysms, 24 (75%) had a wide neck.

RESULTS

All 32 aneurysms were adequately occluded after WEB placement. There were no procedural ruptures and no complications related to the WEB device. No adjunctive stents or balloons

Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study

Editor’s Choice

The authors analyzed all carotid artery dissection tandem occlusion strokes and isolated anterior circulation occlusions from their ongoing prospective stroke data base. For carotid artery dissection, the revascularization procedure consisted of initial distal recanalization by a stent retriever in the intracranial vessel. Following assessment of the circle of Willis, ICA stent placement was only performed in case of insufficiency. Two hundred fifty-eight patients with an anterior circulation stroke were analyzed, including 20 with carotid artery dissection–related occlusion. Only 5 carotid artery dissections (25%) necessitated cervical stent placement. No early ipsilateral stroke recurrence was recorded, despite the absence of stent placement in 15 patients (75%) with carotid artery dissection. Mechanical endovascular treatment of carotid artery dissection tandem occlusions is safe and effective compared with isolated anterior circulation occlusion stroke therapy. The authors favor a complete evaluation of the circle of Willis in these patients, which requires a contralateral femoral puncture, allowing selective contralateral common carotid and vertebrobasilar catheterizations.

Seven AVMs: Tenets and Techniques for Resection

Lawton MT. Seven AVMs: Tenets and Techniques for Resection. Thieme; 2014; 352 pp; 869 ill; $189.99

Cover fo Seven AVMs: Tenets and Techniques for Resection, by LawtonThis is the first edition of Professor Michael Lawton’s Seven AVMs: Tenets and Techniques for Resection. Coming off the heels of the successful book Seven Aneurysms: Tenets and Techniques for Clipping, Lawton presents his approach to AVMs from his vast experience using a methodical and systematic approach to a dynamic and variable pathology.

There are only a handful of surgeons, not only in the country but also in the world, that have the privileged opportunity to operate on this volume of AVMs (over 500). He has courageously taken advantage of this responsibility and turned it into a manuscript that allows the neurosurgery community to learn from his experience.

The book begins with a forward by Professors Albert Rhoton Jr. and Robert Spetzler, both attesting to Dr. Lawton’s surgical expertise and ability to produce a book capable of tackling this daunting feat. The book is then divided into three sections: 1) 10 tenets or general principles for the surgical management of AVMs, 2) the 7 AVMs, and 3) selection strategies.

The hardcover is extensively illustrated with high-quality figures (over 700) including anatomic drawings, operative photographs, and contemporary imaging. To provide a better conceptualization of the AVMs and their relationships to eloquent brain, arteries, vessels, and ventricles, the figures include multiple anatomic illustrations of the AVM (coronal, anterior) plus a surgeon’s view. Furthermore, clear and concise legends supplement the detailed text.

The last section of the book discusses the selection strategies with mention of natural history, grading systems, and multimodality intervention (embolization, radiosurgery). Unfortunately, the ARUBA (A Randomized Trial of Unruptured Brain AVMs) trial was not in press before this book was published; however, Dr. Lawton’s views on this study and its controversies …