6th Annual Meeting of the Society of Vascular and Interventional Neurology

doi:10.1159/000356134

. 2014 Apr;2(2):49–96. doi: 10.1159/000356134

6th Annual Meeting of the Society of Vascular and Interventional Neurology

PMCID: PMC4031774

October 26-27, 2013, Houston, Texas

Guest Editor

Dileep R. Yavagal, Miami, Fla.

S. Karger

Medical and Scientific Publishers Basel • Freiburg • Paris • London • New York • Chennai • New Delhi • Bangkok • Beijing • Shanghai • Tokyo • Kuala Lumpur • Singapore • Sydney

Disclaimer

The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publisher and the editor(s). The appearance of advertisements in the journal is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Drug Dosage

The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.

No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center (see ‘General Information’).

ISBN 978–3–318–02611–5

e-ISBN 978–3–318–02612–2

Contents

57 Outcomes After Endovascular Treatment for Anterior Circulation Stroke Presenting as Wake-Up Strokes Are Not Different Than Those with Witnessed Onset Beyond 8 hours

Aghaebrahim, A.; Leiva-Salinas, C.; Zaidi, S.; Jumaa, M.; Urra, X.; Amorim, E.; Zhu, G.; Jadhav, A.P.; Jankowitz, B.; Wintermark, M.; Jovin, T.

58 Use of Standardized Protocols and Order Sets at a Comprehensive Stroke Center Decreases the Average Hospital Length of Stay for Patients with Non-Traumatic Intracerebral Hemorrhage (ICH)

Bhuva, P.; Phillips, K.D.; Venizelos, A.; Roper, D.; Coulson, J.; Carlson, L.; Robbins, S.; Whitely, M.; Pandhi, A.; Janardhan, V.

59 Endovascular Treatment of Distal PICA Aneurysms Associated with AVMs

Case, D.; Higashimori, T.; Seinfeld, J.

60 Texas Stroke Intervention Pre-Hospital Stroke Severity Scale (aka LEGS score): A Novel Triaging Tool for Interventional Stroke Therapy

Chen, S.; Venizelos, A.; Pandhi, A.; Gianatasio, R.; Coffman, S.R.; Gamber, M.; Hartman, W.T.; Myers, J.H.; Janardhan, V.

61 Current Risk-Adjusted Clinical Outcomes from the INterventional Stroke Therapy Outcomes Registry

Connors, J.

62 Complexity of Treatment for PICA Aneurysm: A Case Series and Review of Literature

Cortez, V.; Taqi, M.; Siddiqi, J.

65 Increase Incidence of Aneurysmal Rupture Less Than 5 mm

Cortez, V.; Sodhi, A.; Ramakrishnan, V.; Taqi, M.; Wolfe, T.

66 Solitaire FR Thrombectomy for Acute Revascularization (STAR) Study in Patients with Acute Ischemic Anterior Circulation Stroke: Subgroup Analyses

Dávalos, A.

67 Features of Capillary Malformation-Arteriovenous Malformation Syndrome Associated Cerebral Vascular Anomalies

Fifi, J.

68 Establishing a Comprehensive Stroke System of Care Increases the Acute Ischemic Stroke Volume and Intravenous Recombinant Tissue Plasminogen Activator (IV r-tPA) Usage

Gianatasio, R.; Venizelos, A.; Roper, D.; Pandhi, A.; Robbins, S.; Guthmann, A.; Coulson, J.; Whitley, M.; Janardhan, V.

69 Comparison of Surgical and Endovascular Approach in Management of Spinal Dural Arteriovenous Fistulas (SDAVF): A Single Center Experience of 27 Patients

Gokhale, S.; Britz, G.; Khan, S.; McDonagh, D.

70 Community Hospitals Within a Regional Stroke Network Can Safely Administer Intravenous Recombinant Tissue Plasminogen Activator (IV r-tPA) in Acute Ischemic Stroke

Hansen, P.A.; Venizelos, A.; Pandhi, A.; Gianatasio, R.; Roper, D.; Roland, A.; Coulson, J.; Robbins, S.; Janardhan, V.

71 Carotid Siphon Calcification Impact on Reperfusion and Outcome in Stroke Intervention

Haussen, D.; Gaynor, B.; Johnson, J.; Peterson, E.; Elhammady, M.; Aziz-Sultan, M.; Yavagal, D.

72 Medical and Endovascular Treatment of Posttraumatic Bilateral Carotid and Right Vertebral Artery Injury: Case Report with 4-Year Follow up and Review of Literature

Higashimori, T.; Kumpe, D.

74 Are Flow-Diverters the Current Best Treatment Option for Ruptured Blister Like Aneurysms?

Hoover, S.; Safavi-Abbasi, S.; Garg, A.; Saucedo, S.

75 Labeled and Off-Labeled Indications and Locations for the Placement of Flow Diverters Across the World: A Review of Literature

Hoover, S.; Safavi-Abbasi, S.; Garg, A.; Saucedo, S.; Tafish, I.

76 ADAPT Technique Clinical Experience in Stroke Thrombectomy at Lutheran Medical Center

Janjua, N.; Farkas, J.; Arcot, K.M.; Walzman, D.E.; Kumar, R.; Delbrune, J.; Papamitsakis, N.; Margulis, Y.; Dash, S.; Levin, K.A.; Azhar, S.

77 A Novel Approach to Diagnose Reversible Cerebral Vasoconstriction Syndrome (RCVS): A Case Series

Kass-Hout, T.; Kass-Hout, O.; Sun, C.H.; Nahab, F.; Nogueira, R.; Gupta, R.

78 Clinical, Angiographic, and Radiographic Outcomes Differences Amongst Mechanical Thrombectomy Devices: Initial Experience of a Large-Volume Center

Kass-Hout, T.; Kass-Hout, O.; Sun, C.H.; Belagaje, S.R.; Anderson, A.M.; Frankel, M.R.; Gupta, R.; Nogueira, R.G.

79 Simultaneous Endovenous Hypothermia and Intra-Arterial Thrombectomy Is Feasible in Patients with Acute Ischemic Stroke

Kenmuir, C.; Polderman, K.; Amorim, E.; Jadhav, A.; Grandhi, R.; Jankowitz, B.; Wechsler, L.; Jovin, T.; Linares, G.

80 Individuals Aged ≥70 years with Aneurysmal Subarachnoid Hemorrhage: Functional Outcome and 10-Years’ Survival

Lindegaard, K.-F.; Bakke, S.J.; Sorteberg, W.

81 Endovascular Repair of the Ruptured Anterior Communication Artery Complex and Wide Neck Aneurysm

Lodi, Y.M.; Reddy, V.V.; Devasenapathy, A.; Swrankar, A.; Sethi, K.; Gaylon, D.; Bajwa, S.

82 Single Balloon Microcatheter Technique for Coiling Wide Necked Aneurysms: A Case Series

Mehta, S.; Einertson, C.J.; Edgell, R.

83 Meta-Analysis of Reversible Cerebrovascular Vasoconstriction Syndrome Without Subarachnoid or Intracerebral Hemorrhage

Mustafa, G.; Dabir, A.; Kamal, H.; Owais, M.; Li, P.; Shafie, M.; Lee, H.; McMurtray, A.; Mehta, B.K.

84 Effect of Clot Characteristics on Successful Recanalization with the Solitaire FR Stent Retriever Device in Acute Ischemic Stroke

Mokin, M.; Morr, S.; Snyder, K.; Levy, E.; Siddiqui, A.

85 Stenting and Angioplasty of Small Cerebral Arteries in Symptomatic Intracranial Atherosclerotic Disease

Nourollah-Zadeh, E.; Castonguay, A.; Kalia, J.; Fitzsimmons, B.-F.; Lazzaro, M.; Lynch, J.; Zaidat, O.O.

89 Comparison of Large Vessel Stroke Patient Outcomes Before and After Initiation of On-Site Endovascular Stroke Treatment Services

Shwe, Y.; Ortega-Gutierrez, S.; Otokiti, A.; Jonna, S.; Altschul, D.; Paramasivam, S.; Berenstein, A.; Fifi, J.T.

90 Single-Center Retrospective Experience with Stentrievers in Acute Ischemic Stroke Treatment

Ramakrishnan, P.; Sun, C.-H.J.; Frankel, M.R.; Anderson, A.M.; Belagaje, S.R.; Nahab, F.; Gupta, R.; Nogueira, R.

91 Geographical Location and Transfer Circuits in Acute Stroke Patients Candidates for Endovascular Therapies

Ribo, M.

92 Stenting of Symptomatic Extracranial Vertebral Artery Occlusions

Streib, C.; Aghaebrahim, N.; Rangaraju, S.; Jadhav, A.; Jankowitz, B.; Jovin, T.

93 Implementation of an ED-Based Rapid Brain-Attack Triage Algorithm in a Regional Tele-Stroke Network Positively Impacts Treatment Rates for Acute Ischemic Stroke

Venizelos, A.; Pandhi, A.; Gianatasio, R.; Chen, S.H.; Hansen, P.A.; Bhuva, P.; Murray, M.M.; Guthmann, A.; Roper, D.; Whitley, M.; Janardhan, V.

94 Cost Efficiency and Follow-Up Data Using the Penumbra Coil 400 for Treatment of Aneurysms in the Cerebrovascular System

Vidal, G.; Milburn, J.; Pansara, A.; Martinez, R.

95 Cost Effectiveness for Intra-Arterial Stroke Therapy Achieved with Image-Based Selection and not with Type of Device

Reese, B.; Young, S.; Stands, K.; Gupta, R.; Mejilla, J.; Hicks, B.J.; Davis, T.; Pema, P.; Budzik, R.; Vora, N.

96 Author Index

Schedule of Events

	Saturday, October 26, 201
7:30–7:40am	Welcome
Randall Edgell, MD
7:40am	Breakfast Symposium
Sponsored by Penumbra
7:40–8:10am	Update on THERAPY Trial
Pooja Khatri, MD, MSc, FAHA
8:10–8:30am	Update on Penumbra 3D Separator Trial
Sophia Janjua, MD

8:30–10:30am	Session 1

8:30–8:45am	SAMMPRIS Trial Final Results
Colin Derdeyn, MD
8:45–9:00am	CHANCE Trial: ICAD Subgroup Results
Liping Liu, MD
9:00–9:15am	Largest Single Center Wingspan Results
Weijian Jiang, MD, PhD
9:15–9:30am	Hong Kong Wingspan Study
Thomas Leung, MD
9:30–9:45am	VISSIT Trial Final Results
Osama Zaidat, MD
9:45–10:00am	The Role of Collaterals in SAMMPRIS and WASID
David Liebeskind, MD
10:00–10:30am	Question & Answer
10:30–11:00am	Break

11:00am–1:20pm	Session 2

11:00–11:15am	Rationale for Stand-Alone Angioplasty in ICAD
David Fiorella, MD, PhD
11:15–11:30am	Angioplasty for ICAD – Where Do We Stand?
To Be Announced
11:30–11:45am	Hope from the Heart – Evolution of Interventional Cardiology
Spencer King, MD
11:45–12:00pm	Hemodynamic vs. Local Perforator Mechanism in ICAD Stroke – Does it Matter?
Alex Abou-Chebl, MD
12:00–12:15pm	Plaque Imaging in Intracranial Atherosclerotic Disease
Juan Arenillas, MD
12:15–12:40pm	Break

12:40–1:30pm	Lunch Symposium

12:40–1:00pm	Update on the DAWN Trial
Raul Nogueira, MD
1:00–1:20pm	Update on the SCENT Trial and Surpass
Ajay Wakhloo, MD, PhD
1:20–1:30pm	Break

1:30–3:00pm	Session 3

1:30–1:45pm	Vertebral Artery Origin Stenosis: Epidemiology and Natural History
Mikael Mazighi, MD
1:45–2:00pm	Short and Medium Term Results in Stenting for Vertebral Artery Origin Stenosis – Review of Existing Data
Randall Edgell, MD
2:00–2:15pm	Trial Design in Vertebral Artery Origin Stenosis
Robert Taylor, MD
2:15–2:30pm	Update on CREST 2
To Be Announced
2:30–2:45pm	Behind the Reimbursement Curtain: Carotid Stenting and CMS
To Be Announced
2:45–3:00pm	Question & Answer
3:00–3:15pm	Break

3:15–3:45pm	Session 4

3:15–3:45pm	Abstracts

3:45–4:15pm	Session 5

3:45–4:15pm	Interesting Case & Complications
4:15–4:30pm	Question & Answer
4:30–4:50pm	Break

4:50–7:30pm	Session 6

4:50–5:05pm	Large Bore Aspiration Catheters and Stent Retrievers – A Match Made in Heaven
Raul Nogueira, MD
5:05–5:20pm	Balloon Guides – There is No Substitute in Acute Stroke Thrombectomy
David Bonovich, MD
5:20–5:35pm	From Access Site to Reperfusion: How Can We Get Faster?
Marc Ribo, MD
5:35–5:50pm	Question & Answer
5:50–6:30pm	Lessons Learned: The Evolution of Endovascular Stroke Therapy
Stanley Barnwell, MD
6:30–7:30pm	Reception

7:30–9:15pm	Dinner Symposium

7:30–8:00pm	Dinner
8:00–8:15pm	IMS III – Final Results and Key Subgroup Analysis
Andrew Demchuk, MD, FRCPC
8:15–8:30pm	MR RESCUE – Final Results
Chelsea Kidwell, MD
8:30–8:45pm	Summary of Randomized Trials in Endovascular Stroke Therapy – Can Different Trials Lead to Different Results?
Tudor Jovin, MD
8:45–9:00pm	Clinical Scores for Patient Selection – The HIAT Score
Amrou Sarraj, MD
9:00–9:15pm	Pre-Hospital and In-Hospital Systems of Care in Endovascular Therapy for Stroke – Radical Change is Needed
Rishi Gupta, MD

Open in a new tab

	Sunday, October 27, 2013
7:30–8:15am	Breakfast Symposium

7:30–7:40am	Update on SWIFT Prime
Jeffrey Saver, MD
7:40–7:50am	Update on REVASCAT Trial
Antonio Davalos, MD
7:50–8:15am	Update on the ESCAPE Trial
Andrew Demchuk, MD, FRCPC

8:15–9:45am	Session 7

8:15–8:30am	Cavernous Carotid Aneurysms in the Age of Flow Diverters
Stanley Barnwell, MD
8:30–8:45am	Flow Diverters: The Communicating Segment and Beyond
Michel Mawad, MD
8:45–9:00am	Is There a Role for Flow Diverters in the Posterior Circulation?
Gabor Toth, MD
9:00–9:15am	Endovascular Therapy for Bifurcation Aneurysms – New Devices
Hashem Shaltoni, MD
9:15–9:30am	Overview of Currently Available Flow Diverters
Joey English, MD
9:30–9:45am	Question & Answer
9:45–10:00am	Break

10:00–11:00am	Session 8

10:00–10:15am	Sclerotherapy of Head and Neck Venous and Lymphatic Malformations
Lucas Elijovich, MD
10:15–10:30am	ARUBA and Treatment of Unruptured AVMs
To Be Announced
10:30–10:45am	Contemporary AVM Embolization: Cure or Adjunct?
Italo Linfante, MD, FAHA
10:45–11:00am	Question & Answer

11:00–11:30am	Session 9

11:00–11:30am	Abstracts

11:30am–1:00pm	Session 10

11:30–12:00pm	Interesting Case & Complications
12:00–12:30pm	Luncheon
12:30–1:00pm	Business Meeting

1:00–2:30pm	Session 11

1:00–1:15pm	What Gets Reimbursed and How Much in 2013?
Nils Mueller, MD
1:15–1:30pm	Telestroke: There is an App for That
Marc Lazzaro, MD, MS
1:30–1:45pm	Endovascular Stroke in the Developing World
Ammar Alkawi, MD
1:45–2:00pm	Standardization of the Neuroendovascular Lab
Vallabh Janardan, MD
2:00–2:15pm	Comprehensive Stroke Center Certification and the Neurointerventionalists
Mark Alberts, MD
2:15–2:30pm	Question & Answer
2:30pm	Closing Remarks and Adjourn
Randall Edgell, MD

Open in a new tab

Interv Neurol. 2014 Apr;2(2):49–96.

Outcomes After Endovascular Treatment for Anterior Circulation Stroke Presenting as Wake-Up Strokes Are Not Different Than Those with Witnessed Onset Beyond 8 hours

Objective

Patients with wake-up stroke are thought to have different outcomes after recanalization compared to patients with witnessed late time of onset. We sought to verify this hypothesis by determining clinical outcomes, mortality, infarct volume, and rate of parenchymal hematoma (PH) in patients with anterior circulation large vessel occlusion stroke (ACLVOS) treated with endovascular therapy at our center.

Methods

Retrospective review of a prospectively acquired database from consecutive patients meeting the following criteria: (1) ACLVOS, (2) endovascular treatment initiated beyond 8 hrs from time last seen well (TLSW) or wake up stroke (WUS). Treatment selection was based on the presence of a small infarct core/large penumbra assessed through visual inspection on MRI or CTP by the treating physician. In addition, imaging characteristics including pre-procedure infarct volumes and final infarct volumes were calculated through automated volumetric analysis.

Results

We identified 192 patients. Patients were divided into two groups. Group 1: patients with WUS (39%, n = 75). Group 2: patients with witnessed onset beyond 8 hrs (54%, n = 104) and patients without witnessed onset but TLSW greater than 8 hrs (7%, n = 13) who were not WUS. The groups were comparable for median age (68 vs. 65, P = 0.25), baseline median NIHSS (15 vs. 13, P = 0.14), pre infarct volume (14 mL vs. 13 mL, P = 0.57) and rate of successful recanalization (68% vs. 68%, P = 0.96). The proportions of patients with modified Rankin Scale 0 to 2 (43% vs. 50%, P = 0.31), any symptomatic intracerebral hemorrhage (18% vs. 12%, P = 0.29) and final infarct volume (47 mL vs. 46 mL, P = 0.93) were also comparable. Further, successful recanalization (TICI 2b or 3) was associated with better outcome (P < 0.001) and significantly smaller infarct growth (P < 0.001). Multivariate logistic regression model identified only age (OR = 0.94, 95% CI 0.91–0.97, P < 0.001) successful recanalization (OR 2.9, 95% CI 1.2–7.2, P = 0.018) and final infarct volume (OR 0.98, 95% CI 0.98–0.99, P < 0.001) but not mode of presentation as predictors of favorable outcomes.

Conclusion

In patients with ACLVOS presenting beyond 8 hours from TLSW who are selected based on similar imaging characteristics, clinical outcomes following endovascular treatment do not seem to differ according to mode of presentation relative to TLSW.

Interv Neurol. 2014 Apr;2(2):49–96.

Use of Standardized Protocols and Order Sets at a Comprehensive Stroke Center Decreases the Average Hospital Length of Stay for Patients with Non-Traumatic Intracerebral Hemorrhage (ICH)

Background

Establishing and implementing standardized protocols and order sets can be a time-consuming and resource-intensive process. There is limited information on the impact of such standardized protocols and order sets on the hospital length of stay in patients with non-traumatic ICH.

Methods

Standardized protocols and order sets were implemented in 2010 as part of the development of a Comprehensive Stroke Center and regional stroke network of 11 hospitals. Patients with non-traumatic ICH were identified based on in-patient hospital discharge ICD-9 codes from 2008 to 2011 and hospital length of stay data was collected.

Results

A total of 339 patients were hospitalized with non-traumatic ICH over the 4-year period. The average hospital length of stay for patients with non-traumatic ICH decreased from 8.7 days in 2008 to 7.0 days in 2011, a 19.5% reduction.

Conclusion

Use of Standardized Protocols and Order Sets at a Comprehensive Stroke Center is associated with a significant decrease in the average hospital length of stay for patients with non-traumatic ICH.

Interv Neurol. 2014 Apr;2(2):49–96.

Endovascular Treatment of Distal PICA Aneurysms Associated with AVMs

David Case, Taka Higashimori, Joshua Seinfeld

The association of posterior fossa arteriovenous malformation (AVM) and posterior inferior cerebellar artery (PICA) aneurysms has been previously documented in the literature. We report three cases of distal PICA aneurysms associated with posterior fossa AVMs between June 2009 and July 2013 at our institution. Three patients presented with Fischer grade 4 subarachnoid hemorrhage (SAH). Two patients presented as Hunt and Hess 4 and one as Hunt and Hess 5. CTA was used in the initial evaluation. In each case, distal fusiform aneurysms of the posterior inferior cerebellar artery located along the roof of the fourth ventricle were identified. While the aneurysms were easily visualized on non-invasive imaging, all associated AVMs were obscured by adjacent dural sinuses, bone artifact and not noted on the official radiologic interpretations. Angiography was required for visualization of the AVMs. Four aneurysms were treated by endovascular techniques in 3 patients within 24 hours of presentation utilizing liquid embolic agents (onyx 2, NBCA 1) for parent vessel sacrifice. In two patients the AVM was also embolized at the time of aneurysm treatment using onyx (1 partial and 1 complete).

Conclusions

Non-invasive imaging did not reveal associated small mid-line superior cerebellar AVMs with radiographically identified PICA aneurysm suggesting invasive imaging studies are needed. In addition, endovascular treatment with parent vessel sacrifice and AVM embolization is a potential approach to these patients.

Fig. 1 — Distal R PICA aneurysm and superior cerebellar AVM

Interv Neurol. 2014 Apr;2(2):49–96.

Texas Stroke Intervention Pre-Hospital Stroke Severity Scale (aka LEGS score): A Novel Triaging Tool for Interventional Stroke Therapy

Sherman Chen, Alexander Venizelos, Abhi Pandhi, Ryan Gianatasio, Stewart R Coffman, Mark Gamber, W Tim Hartman, John H Myers, Vallabh Janardhan

Background

A pre-hospital stroke severity scale that correlates well with an NIHSS of 10 or greater (NIHSS ≥10 correlates well with large vessel occlusions) but is easier and faster to perform would be very useful triaging tool to emergency medical services (EMS).

Methods

The LEGS score is a shortened NIHSS-5. LEGS score stands for Leg strength, Eyes/visual fields, Gaze, Speech/language. LEGS score (0-16) as well as the full NIHSS (0-42) were performed in the emergency department over a 6-month period.

Results

A total of 182 consecutive ischemic stroke patients were evaluated. LEGS score 4 or greater was a good predictor of an NIHSS of 10 or greater (59/182; positive predictive value 92%; and specificity 95%) and false positives noted was 5/182. LEGS score of less than 4 was a good predictor of an NIHSS of less than 10 (108/182; negative predictive value 91%; and sensitivity 95%) and false negatives noted was 10/182.

Conclusion

LEGS score of 4 or greater is useful to triage moderate-severe stroke patients (NIHSS of 10 or greater) to a comprehensive stroke center for consideration for Interventional Stroke therapy.

Interv Neurol. 2014 Apr;2(2):49–96.

Current Risk-Adjusted Clinical Outcomes from the INterventional Stroke Therapy Outcomes Registry

John Connors

Introduction

The INterventional Stroke Therapy Outcomes Registry (INSTOR®) is a complete process improvement tool combined with the ability to perform complex analyses of clinical outcomes for all forms of acute stroke therapy, including intravenous (IV) as well as endovascular (IA).

Methods

A custom software development company was employed to create a dedicated on-line national registry for tracking hospital processes and performance trends, and that could perform instant complex single and multifactorial analyses of clinical outcomes (90-day modified Rankin Score (mRS) based upon numerous patient-specific characteristics as well as clinical and performance-based characteristics.

Results

Some of the results to be presented include dramatically varying outcomes for all forms of treatment based upon initial NIHSS. Concerning IV TPA, for NIHSS 0-5, mRS 0-1 was 67%; 6–9, 38%; 10–14, 20%; 15–19, 10%, and for NIHSS 20 or over, mRS 0-1 was zero %. For IV+IA treatment, there was a similar pattern – outcomes now listed as mRS 0-2. For NIHSS 0-5, mRS 0-2 was 50%; 6–9, 80%; 10–14, 72%; 15–19, 42%, 20–24, 33%, over 24, 60%. For IA alone – numbers again listed as mRS 0-2, for NIHSS 0-5, mRS 0-2 was 42%; 6–9, 42%; 10–14, 60%; 15–19, 18%; 20–24, 20%, over 24, 18%.

Conclusion

INSTOR is capable of calculating both single and multifactorial risk-adjusted analyses of clinical outcomes for all forms of emergency stroke treatment and these will be presented.

Interv Neurol. 2014 Apr;2(2):49–96.

Complexity of Treatment for PICA Aneurysm: A Case Series and Review of Literature

Vladimir Cortez, Muhammed Taqi, Javed Siddiqi

The frequency of posterior circulation aneurysms is 15% with 3% arising from the PICA. Our institution is presenting a 3-case series of such aneurysms.

Case 1

75 year-old Caucasian female with acute SAH from a ruptured right distal PICA aneurysm. Patient presented with GCS of 11T with diffuse intraventricular SAH. Initial angiogram showed a distal saccular right PICA aneurysm that was deemed not appropriate for coiling. The patient underwent a right suboccipital craniotomy for clipping of aneurysm. Post-operative, the patient recovered and was eventually discharge to rehab.

Case 2

80 year-old Caucasian female with ruptured left proximal PICA aneurysm. The patient presented with GCS of 10T. Initial angiogram showed a possible re-bleed. The patient was then taken for a left suboccipital craniotomy for clipping of aneurysm. The patient's post-operative course showed dependency of the vent. The family withdrew treatment and concentrated on comfort care.

Case 3

57 year-old Hispanic male presented with a 5-day history of headache and subacute SAH. On angiogram, a PICA aneurysm was identified at the VA junction. The patient underwent coiling of aneurysm but with intra-procedural rupture. The aneurysm was able to be coil with control of the hemorrhage. Post-operatively the patient recovered, but develop hydrocephalus, which was treated with shunting. The patient was discharge to home.

By far, aneurysms of the PICA region are the most difficult to treat. Surgery for these aneurysms are challenging due to the location and intimate relation to the brainstem. On the other hand, endovascular results of PICA aneurysms are not well established.

Interv Neurol. 2014 Apr;2(2):49–96.

Increase Incidence of Aneurysmal Rupture Less Than 5 mm

Vladimir Cortez, Ajeet Sodhi, Vivek Ramakrishnan, Muhammed Taqi, Thomas Wolfe

Subarachnoid hemorrhage (SAH) from rupture aneurysms is a common presentation to the ED in the US and abroad with an estimated aneurysmal hemorrhage in most western populations of 6–8 per 100,000. Also, SAH are commonly associated with high morbidity and mortality. However, unruptured aneurysms merit treatment since their outcome is also poor even under the best circumstances. About 65% of patients will die from their first hemorrhage, and even in patients with no neurologic deficits after rupture of aneurysm, only 46% will recover fully and 44% will return to their jobs. There are numerous recommendations for treating unruptured aneurysms. Most guidelines suggest that unruptured aneurysms of >10 mm should be treated; 7–9 mm aneurysms in young and middle-aged patients need treatment as well. Aneurysms less than 5 mm in size usually can be observed with serial angiography based on recent guidelines.

Our institution will present a case series of 5 patients with aneurysmal rupture of aneurysms <5 mm in size. Locations of these aneurysms were in the anterior and posterior circulation. From this series, 2 patients presented SAH with aneurysms less than 2 mm in size. The patients were of young age and with normal health. The overall degree of outcome was marginal. The increase rate of SAH from aneurysms less than 5 mm suggest an increase trend and shift in the normal pathophysiology of small and micro aneurysms, as initially thought. In all, rupture of small and micro aneurysm should prompt to re-examine their overall rupture rate on a national scale.

Interv Neurol. 2014 Apr;2(2):49–96.

Solitaire FR Thrombectomy for Acute Revascularization (STAR) Study in Patients with Acute Ischemic Anterior Circulation Stroke: Subgroup Analyses

Antoni Dávalos ¹

Background

The STAR study showed that treatment with the Solitaire^TM FR device in intracranial anterior circulation occlusions results in high rates of revascularization, low risk of clinically relevant procedural complications, and good clinical outcomes in combination with low mortality at 90 days. We present the results of subgroup analyses.

Methods

In a prospective, observational, singleHarm study, 202 patients (median age 72; 60% female; median NIHSS 17; median time to groin puncture (TGP), 238 min) undergoing mechanical thrombectomy for acute ischemic stroke in the anterior circulation were enrolled in 14 selected dedicated comprehensive stroke centers in Europe, Canada and Australia. Subgroup analyses were based on revascularization (TICI 2bH3) and functional independence (mRS 0–2) at day 90.

Findings

Analyzed subgroups were intracranial MCA (82%) vs. ICA occlusion, general anesthesia (72%) vs. sedation, IV tPA (59%) vs. no tPA, MRI use (26%) vs. CT for patients’ selection, collateral status 3H4 (36/128, 28%) vs. 0H2 (ASITN/SIR Collateral Flow Grading System), and TGP <4.5 h (64%) vs. >4.5 h. Revascularization rate was similar among the different subgroups. Good functional outcome was significantly higher in patients with good collaterals (72% vs. 55%, p = 0.034) and treated within 4.5 h (65% vs. 42%, p = 0.002). Functional recovery (mRS, 0H1) was higher in MCA occlusions (47% vs. 25%, p = 0.016). No significant differences were found in the other subgroups.

Interpretation

Thrombectomy with the Solitaire FR device results in better clinical outcomes in patients with good collaterals. The present findings reinforce the need to shorten the time to groin puncture as a way to achieve favorable outcomes.

Interv Neurol. 2014 Apr;2(2):49–96.

Features of Capillary Malformation-Arteriovenous Malformation Syndrome Associated Cerebral Vascular Anomalies

Johanna Fifi

Background

Capillary malformation-arteriovenous malformation (CM-AVM) syndrome is an autosomal dominant disorder caused by mutations in the RASA1 gene. The hallmark is cutaneous capillary malformations. High flow AVMs occur in about 1/3 of patients, with cerebral malformations in about 10%. We evaluate the clinical and radiographic features of cerebral malformations in CM-AVM patients.

Methods

Since 2006, pediatric patients presenting to our center with head and neck high flow vascular malformations have been screened for capillary malformations. Our database of pediatric head and neck vascular malformations was reviewed for patients with capillary malformations. Patients with only facial arteriovenous malformations were excluded. Clinical and radiographic features were reviewed.

Results

9 patients were found to have high flow head and neck malformations and CM. 1 patient with an ear AVM was excluded. Of the remaining, 4 patients had confirmed positive genetic mutation in the RASA1 gene. All four of these patients had complex pial arteriovenous fistulas – One was supratentorial and three were in the posterior fossa. One premature infant with a complex posterior fossa lesion and heart failure died shortly after birth. One infant with mild heart failure is on medication and awaiting treatment. The other two were asymptomatic and treated with embolization. These patients are neurologically intact and reaching developmental milestone. 3/4 patients had first degree relative with CM with or without AVM. One patient with vein of Galen malformation and CM has tested negative for RASA1 mutation. The other three patients have not yet been tested. Of these, two have pial arteriovenous fistula which have been treated. One 2 year old had a multifocal dural arteriovenous fistula.

Conclusion

Cerebral vascular anomalies in CM-AVM syndrome are often complex lesions. Thus far, all confirmed RASA1 mutation patients at our center have pial arteriovenous fistulas. Vein of Galen malformation and dural AVM may also be associated. Pediatric patients with these diagnoses should be screened for CM. The diagnosis of CM-AVM with RASA1 mutation plays a role in family planning and screening of other family members.

Interv Neurol. 2014 Apr;2(2):49–96.

Establishing a Comprehensive Stroke System of Care Increases the Acute Ischemic Stroke Volume and Intravenous Recombinant Tissue Plasminogen Activator (IV r-tPA) Usage

Ryan Gianatasio, Alexander Venizelos, Debbie Roper, Abhi Pandhi, Scott Robbins, Anita Guthmann, Jeff Coulson, Mark Whitley, Vallabh Janardhan

Background

Comprehensive Stroke Systems of Care are needed across the country. However, there is limited information on the growth of acute ischemic stroke volumes within hospitals in a regional stroke network and the associated IV r-tPA rates.

Methods

A Comprehensive Stroke System of Care was developed in 2010 and included 5 hospitals that were certified primary stroke centers. Acute ischemic stroke volume was identified based on in-patient hospital discharges (ICD-9 codes) from 2008 to 2012. IV r-tPA usage was identified based on procedure codes for intravenous thrombolytic administration and data collected by hospital stroke coordinators.

Results

A total of 6,311 patients were hospitalized with acute ischemic stroke over a 5-year period. Acute ischemic stroke volumes grew from 902 in 2008 to 1493 in 2012 with a growth rate of 65.5%. The IV r-tPA usage rates increased from 7.10% in 2008 to 13.13% in 2012 with a growth of 6.03%.

Conclusion

Comprehensive Stroke System of Care positively impacts stroke volumes in all the hospitals within the regional stroke network and is associated with increased IV r-tPA rates.

Interv Neurol. 2014 Apr;2(2):49–96.

Comparison of Surgical and Endovascular Approach in Management of Spinal Dural Arteriovenous Fistulas (SDAVF): A Single Center Experience of 27 Patients

Sankalp Gokhale, Gavin Britz, Shariq Khan, David McDonagh

Background

Spinal Dural Arteriovenous Fistula (SDAVF) is a rare spinal vascular malformation with an annual incidence of 5–10 cases per million. The data on efficacy, recurrence rates and complications of endovascular versus surgical treatment of SDAVF is limited.

Methods

We conducted a retrospective chart review of 27 adult patients with a diagnosis of SDAVF and who underwent treatment at Duke University Hospital between 1/1/1993 and 1/1/2012. We compared the outcome measures by Aminoff-Logue score (ALS) in patients who underwent treatment with endovascular embolization versus surgical ligation of fistula. We compared complication rates; recurrence rates as well as data on long term follow up in these patients.

Results

Out of total 27 patients in the study, 10 patients underwent endovascular embolization (Onyx was used in 5 patients and NBCA in 5 patients) as the first line therapy. 17 patients underwent surgical ligation as initial therapeutic modality. Patients in both groups showed significant equivalent improvement in clinical status (ALS) after treatment. 1 patient in endovascular group developed spinal infarction due to accidental embolization of medullary artery. 3 patients in embolization group (onyx) had recurrence of fistula during the course of follow up requiring surgical ligation. 2 patients in surgical group developed local wound infection.

Conclusions

Endovascular embolization and surgical ligation are both effective treatment strategies for SDAVF. Endovascular approach with onyx is associated with higher incidence of recurrence, as compared to NBCA. In our cohort, surgical ligation was associated with higher incidence of post-operative infection rate as compared to endovascular approach.

Interv Neurol. 2014 Apr;2(2):49–96.

Community Hospitals Within a Regional Stroke Network Can Safely Administer Intravenous Recombinant Tissue Plasminogen Activator (IV r-tPA) in Acute Ischemic Stroke

Paul A Hansen, Alexander Venizelos, Abhi Pandhi, Ryan Gianatasio, Debbie Roper, Alex Roland, Jeff Coulson, Scott Robbins, Vallabh Janardhan

Background

Despite FDA approval in 1996, the use of IV r-tPA in acute ischemic stroke remains relatively low (3–4%) partly because of the concerns for symptomatic intra-cerebral hemorrhage (6–12%).

Methods

A Comprehensive Stroke System of Care was developed in 2010 and included 5 certified stroke centers. Standardized emergency department-based (ED) algorithms were implemented and stroke coordinators tracked protocol violations. ED physicians administered IV r-tPA with vascular neurology expertise via Tele-phone or via Camera. IV r-tPA usage was identified based on procedure codes for intravenous thrombolytic administration on in-patient hospital discharges from 2008 to 2012. Symptomatic intra-cerebral hemorrhage was defined based on the ECASS criteria.

Results

A total of 6,311 patients were hospitalized with acute ischemic stroke over 5-year period. The IV r-tPA usage rates increased from 7.10% in 2008 to 13.13% in 2012 and the associated symptomatic intra-cerebral hemorrhage rate dropped from 4% in 2008 to 1% in 2012.

Conclusion

Community hospitals within a regional stroke network can safely administer IV r-tPA with low rates of symptomatic intra-cerebral hemorrhages comparable to the results of controlled clinical trials.

Interv Neurol. 2014 Apr;2(2):49–96.

Carotid Siphon Calcification Impact on Reperfusion and Outcome in Stroke Intervention

Diogo Haussen, Brandon Gaynor, Jeremiah Johnson, Eric Peterson, Mohamed Elhammady, Mohammad Aziz-Sultan, Dileep Yavagal

Purpose

The degree of coronary artery calcification has been shown to predict outcomes in coronary artery disease. The impact of intracranial carotid artery calcification on the prognosis of acute ischemic stroke (AIS) is unknown. We sought to examine if the degree of intracranial carotid artery calcification influences reperfusion or outcomes in AIS intervention.

Materials-and-Methods

We retrospectively reviewed all anterior circulation large vessel occlusion AIS cases that underwent intra-arterial therapy from January 2009 to July 2012. Clinical and radiographic data was collected. Non-contrast brain CT scans were assigned a Calcium Extent Score (degree of calcification of the carotid wall circumference), Calcium Thickness Score (thickness of the calcified plaque), and total Carotid Siphon Calcium (CSC) Score (8-point scale).

Results

One hundred eighteen patients met inclusion criteria. The mean age was 65.4 ± 15.6 years and 36% were female. Calcification was present in the intracranial carotid artery of 84 patients (71%). Inter-rater agreement for total CSC score was strong (Spearman's rho = 0.883, p < 0.001). The mean Calcium Extent Score was 1.5 ± 1.3, Calcium Thickness Score 1.3 ± 1.0 and total CSC Score 2.8 ± 2.2. Reperfusion and mRS were not associated with CSC. Multivariate linear regression analysis revealed that older age, history of coronary disease and cervical internal carotid occlusion/near-occlusion were independently associated with higher total CSC scores.

Conclusion

Extensive calcification on the intracranial carotid artery does not have impact on reperfusion or clinical outcomes in AIS patients undergoing endovascular therapy. Higher CSC scores are associated with coronary artery disease, increasing age and cervical internal carotid artery occlusion/near-occlusion.

Interv Neurol. 2014 Apr;2(2):49–96.

Medical and Endovascular Treatment of Posttraumatic Bilateral Carotid and Right Vertebral Artery Injury: Case Report with 4-Year Follow up and Review of Literature

Takamasa Higashimori, David Kumpe

Choice of appropriate medical and endovascular treatment of traumatic cervical vascular injury is still controversial. CADISS trial is still ongoing to compare anticoagulation and antiplatelet agents for prevention of stroke after carotid and vertebral artery dissection. We present this case of blunt cervical vascular injury complicated with embolic stroke, with 4 year follow up to assess effective treatment and outcome of the patient.

48 year-old healthy female presented with blunt cervical injury after being involved in a T-bone motor vehicle crash while sitting in a passenger seat. Exam revealed transient tongue numbness with dysarthria, which resolved in ED. While initial CTA neck showed only mild RICA dissection, repeat CTA revealed significant increase in the size of pseudoaneurysm (PA) of RICA dissection, as well as new small dissections/PAs of the LICA and R vertebral artery (RVA). The PA in the LICA extended proximally from its neck, resulting in prolonged contrast stasis in the proximal end of the PA. RICA stent was placed due to continued worsening of dissection, and coumadin was replaced by plavix post-stent placement.

12 days post-stent placement, she presented with acute onset of nonfluent aphasia, and CTA/MRI revealed LMCA stroke with distal L M1 occlusion, which was treated with IA ReoPro. Thrombus was now present in the region of contrast stasis in the PA. LICA stent was placed 9 days later after confirming autolysis of thrombus with heparin gtt. Nine weeks later, RVA was stented without complications. No restenosis, PA or thrombus formation was noted on four followup arteriograms over the next 4 years with excellent clinical outcome (mRS = 1).

This case suggests the use of anticoagulation over antiplatelet agents may be beneficial in a subset of patients with cervical PA with an angiographic evidence of contrast stasis, which can increase the risk of thrombus formation. In addition, endovascular stent placement is a safe and effective long-term option for treating posttraumatic cervical artery dissection and PA.

Fig. 4 — Diffusion-Weighted image at the time of stroke.

Interv Neurol. 2014 Apr;2(2):49–96.

Are Flow-Diverters the Current Best Treatment Option for Ruptured Blister Like Aneurysms?

Steven Hoover, Sam Safavi-Abbasi, Ankur Garg, Scott Saucedo

Introduction

The term ‘blister aneurysm’ or ‘blood blister aneurysms’ (BBAs) has been used to describe broad-based aneurysms arising from non-branching sites of the supraclinoid internal carotid artery. Histologically, these lesions have been shown to represent focal wall defects covered with thin, fibrous tissue and adventitia, lacking the usual collagen layer. These lesions are often extremely challenging to treat and their optimum treatment modality is still not known. Compared with saccular aneurysms in similar locations, these lesions tend to have a more precipitous course as they are reported to rapidly enlarge and rebleed, sometimes even after treatment. The objective of this study was to analyze the past and current therapeutic modalities for the treatment of these lesions.

Methods

A PubMed search using following search terms: blister aneurysm, blood blister aneurysms, and dorsal internal carotid artery wall aneurysms. These studies were then extensively reviewed for the treatment utilized.

Results

Following microsurgical techniques have been described in the literature: clipping with or without wrapping and extracranial-intracranial bypass with trapping of the internal carotid artery. Following endovascular techniques have been described: coiling, stent-assisted coiling, telescoping stents with our without coiling, endovascular parent vessel sacrifice, and most recently the use of flow diverters (Pipeline embolization device and SILK). Combination microsurgical and endovascular treatments are also reported.

Discussion

Given the recent success with stent-in-stent techniques and the hazardous histology of blister aneurysms, endovascular treatment with flow-diverters may be the current best endovascular treatment of these lesions. However, long term outcome data especially in the setting of acute subarachnoid hemorrhage and/or intraventricular drains, is warranted.

Interv Neurol. 2014 Apr;2(2):49–96.

Labeled and Off-Labeled Indications and Locations for the Placement of Flow Diverters Across the World: A Review of Literature

Steven Hoover, Sam Safavi-Abbasi, Ankur Garg, Scott Saucedo, Islam Tafish

Introduction

Flow diverters are new-generation endoluminal devices designed to treat aneurysms by diverting the blood flow away from the aneurysm thus creating an environment conducive for intra-aneurysmal thrombosis and eventual exclusion of the aneurysm. Two flow-diverters are currently available for commercial use: Pipeline embolization device (PED; ev3, Irvine, California) and SILK (Balt Extrusion, Montmorency, France). As per the Instructions for Use (IFU) flow diverters are indicated for the endovascular treatment of adults (22 years of age or older) with large or giant wide-necked intracranial aneurysms in the internal carotid artery from the petrous to the superior hypophyseal segments. However, since introduction these devices have been extensively used for treatment of posterior cerebral circulation lesions, as well as distally located lesions in the anterior intracranial circulation. The objective of this literature review was to analyze the labeled as well as off-labeled uses of flow-diverters in terms of placement locations and indications across the world.

Methods

PubMed search was performed using following search words: Pipeline embolization device (97 results), Pipeline stent (81 results), silk stent (56 results), silk flow diverter (20 results), and flow diverter (103 results). These studies were then reviewed for indication and location of the flow diverter placement.

Results

Flow diverters were found to have been placed in following anatomical locations: internal carotid cervical segment, internal carotid petrous segment, internal carotid cavernous segment, internal carotid supraclinoid segment, posterior communicating artery, anterior cerebral artery A1 segment, anterior cerebral artery A1/A2 segments, anterior communicating artery, middle cerebral artery M1 segment, middle cerebral artery bifurcation, middle cerebral artery proximal M2 segment, intracranial vertebral artery, posterior inferior cerebellar artery, basilar artery, superior cerebellar artery, posterior cerebral artery P1 segment, and posterior cerebral artery P2/P3 segments. Analysis of indications for use revealed use of flow diverters for treatment of unruptured and ruptured aneurysms, especially aneurysms with fusiform or blister configuration, giant aneurysms, recurrent aneurysms, aneurysm that have failed other treatments, and dissecting and traumatic intracranial aneurysms. Other indications included direct carotid-cavernous fistulas, spontaneous dissections with pseudoaneurysms, a case of middle cerebral artery compromise following surgical clipping of internal carotid terminus aneurysm, a case of flow diverter use as rescue therapy to treat dissection and vessel perforation following angioplasty of the basilar artery, and a case of telescoped flow diverters in the management of symptomatic chronic carotid occlusion.

Conclusion

Flow diverters continue to have wide-spread use as per their original intended indication. However a review of literature revealed their wide-spread evolving use for additional indications and locations. Further studies and reviews will be needed to determine the efficacy and safety of these devices in these extended indications.

Interv Neurol. 2014 Apr;2(2):49–96.

ADAPT Technique Clinical Experience in Stroke Thrombectomy at Lutheran Medical Center

Purpose

The new material composition and larger, tapered lumen of the Penumbra MAX microcatheters are designed to improve navigation and enhance aspiration, permitting the ‘ADAPT’ technique (aspiration thrombectomy without the use of a separator). We sought to report our outcomes using this technique with the prior (5 MAX) and newer (5 MAX ACE) generation Penumbra devices.

Methods

Demographic, clinical, and radiographic data from 21 consecutive acute stroke cases treated with 5MAX ACE (n = 7) and 5MAX (n = 14) from September 2012 through July 2013 were collected.

Results

Mean age was 74 ± 12 years; median admission National Institutes of Health Stroke scale score (NIHSSS) was 18 (8–29). Occlusions were in the middle cerebral artery (MCA) M1/M2 (n = 13), internal carotid artery (ICA) or ICA/MCA (n = 5), and vertebrobasilar arteries (n = 3). All patients presented with thrombolysis in cerebral ischemia (TICI) 0 or 1. No adjuvant devices were used. Median discharge NIHSSS was 6 (0–29). No complications occurred. One death due to cardiac arrest occurred 15 days post-procedure.

All 5MAX ACE patients achieved TICI 2b/3, while 86% of 5MAX patients did. Puncture to revascularization time was 38 min with the 5MAX ACE and 88 min with the 5MAX. First diagnostic angiogram to revascularization time was 22 min with the 5MAX ACE and 46 min with the 5MAX.

Conclusions

The ADAPT technique yields high rates of revascularization with minimal vessel trauma and resultant hemorrhage. Newer devices further improve on efficiency of revascularization. As ongoing experience accrues, larger studies should be performed to verify these findings.

Interv Neurol. 2014 Apr;2(2):49–96.

A Novel Approach to Diagnose Reversible Cerebral Vasoconstriction Syndrome (RCVS): A Case Series

T Kass-Hout, O Kass-Hout, CH Sun, F Nahab, R Nogueira, R Gupta

Background and Purpose

Reversible cerebral vasoconstriction syndrome (RCVS) is classically a clinical diagnosis with vascular imaging showing vasoconstriction of the cerebral vasculature. We present a diagnostic test that may assist in the clinical diagnosis and facilitate treatment.

Methods

From October 1, 2010 to July 1, 2013 we identified consecutive patients who presented with a presumptive diagnosis of RCVS and underwent cerebral diagnostic angiogram with intra-arterial vasodilator therapy. Medical records including clinical presentation, radiographic and angiographic images were all reviewed.

Results

We identified a total of 6 patients (Four females, age range 37–56; mean 49 years) who met our inclusion criteria. Four patients received a combination of Milrinone and Nicardipine infusion either in the internal carotid arteries (ICA) or in the left vertebral artery (VA); the remaining of the patients received IA therapy solely with Nicardipine. Four patients had a positive angiographic response, defined as significant improvement or resolution of the blood vessels irregularities. All four patients had a definite discharge diagnosis of RCVS. The remaining two patients had a negative angiographic response, based on their clinical and radiographic course both had a final diagnosis of intracranial atherosclerotic disease (ICAD).

Conclusion

Our small case series suggest that Intra-arterial (IA) administration of vasodilators is safe and may aid in distinguishing vasodilator responsive syndromes from other pathologies. Further study is required with long term clinical outcome to determine the utility of this diagnostic test.

Interv Neurol. 2014 Apr;2(2):49–96.

Clinical, Angiographic, and Radiographic Outcomes Differences Amongst Mechanical Thrombectomy Devices: Initial Experience of a Large-Volume Center

T Kass-Hout, O Kass-Hout, CH Sun, SR Belagaje, AM Anderson, MR Frankel, R Gupta, RG Nogueira

Background and Purpose

Time dependent reperfusion has been established with endovascular treatment of acute ischemic stroke (AIS). There are limited data on the comparative performance of FDA cleared devices for mechanical thrombectomy. Here, we compare the angiographic, radiographic, and clinical outcomes amongst the three device categories currently available in the U.S.

Methods

Retrospective review of endovascularly treated large vessel AIS in a large academic center. Data from all consecutive patients who underwent clot retrieval using Merci, Penumbra, or Stent-Retrievers (SR) from September 2010 to November 2012 was collected. Baseline characteristics, rates of successful recanalization (TICI 2b-3), symptomatic intracebral hemorrhage (sICH), final infarct volume, 90-day mortality, and independent functional outcomes at 90 days were compared across the 3 groups.

Results

The entire cohort included 287 patients. There were no statistically significant differences in the rate of sICH (7% vs. 7% vs. 6%, P = 0.921) and infarct volume (66.9 vs. 69.5 vs. 59.8, P = 0.621) between the SR, Merci and Penumbra respectively. Better functional outcomes were found with Penumbra and SR vs. Merci (41% vs. 36% vs. 25% respectively, P = 0.079). Complete or near complete (TICI 2b/3) reperfusion was higher in the SR and penumbra groups compared to the merci (86% vs. 78% vs. 70% respectively, P = 0.027). A binary logistic regression showed that SR was an independent predictor of good functional outcome (OR, 2.27; 95% CI, 1.018 to 5.048; P = 0.045).

Conclusion

Although our initial data confirms the superiority of SR technology over the Merci device, there was no significant difference in near complete/complete reperfusion, final infarct volumes, or clinical outcomes between SR and Penumbra thrombo-aspiration.

Interv Neurol. 2014 Apr;2(2):49–96.

Simultaneous Endovenous Hypothermia and Intra-Arterial Thrombectomy Is Feasible in Patients with Acute Ischemic Stroke

Cynthia Kenmuir, Kees Polderman, Edilberto Amorim, Ashutosh Jadhav, Ramesh Grandhi, Brian Jankowitz, Lawrence Wechsler, Tudor Jovin, Guillermo Linares

Background

Hypothermia is a promising neuroprotectant and may ameliorate reperfusion injury. Easy access to the femoral vein allows it to be combined with intra-arterial therapy.

Methods

Consecutive patients with acute ischemic stroke receiving intra-arterial therapy were studied. A femoral arterial sheath and femoral venous catheter were placed for hypothermia induction with cold saline infusion. Goal temperature prior to reperfusion was 35°, followed by 32° for a total of 24 hours. Patients were rewarmed at 0.2°/hour.

Results

Twenty-two patients were studied, five were women. Median age was 62 (range 47–80), NIHSS was 15 (13–32), time from last known well was 4 hours (1–10), and ASPECTS was 8 (7–10). There were no groin complications. There were four intubations unrelated to the procedure. Five patients developed pneumonia. One patient was diagnosed with a DVT and one with a PE. Symptomatic hemorrhage occurred in two patients (7.6%). Six patients died (27%), four after withdrawal of care. Eleven patients were discharged to rehabilitation (50%) and five to skilled nursing facilities (22.7%).

Conclusions

Combined endovenous hypothermia and intra-arterial therapy for acute ischemic stroke is feasible. There is no increase in symptomatic hemorrhage rates. This data supports the planning of a phase 2 trial to optimize temperature goals and length of the intervention.

Interv Neurol. 2014 Apr;2(2):49–96.

Individuals Aged ≥70 years with Aneurysmal Subarachnoid Hemorrhage: Functional Outcome and 10-Years’ Survival

Karl-Fredrik Lindegaard, Søren Jacob Bakke, Wilhelm Sorteberg

We assessed outcome and long-term survival after aneurysmal SAH in individuals aged ≥70 years.

Patients and Methods

122 individuals aged ≥70 years (median 74.3, range from 70 to 85 years, (70% females) were admitted with proven aneurysmal SAH between 1996 and 2004. 96 patients had aneurysm repair (surgical management – microsurgical: 30, endovascular: 66), whereas 26 patients had no repair (non-surgical): 15 of whom were denied on grounds of age alone. There was no significant difference (p > 0.3) as to Clinical grade, GCS, CT score (Fisher) and aneurysm size (p > 0.11) between surgical and non-surgical patients.

Results

The 90-days mortality in surgical patients was 21/96 (22%; 95%CI: 14–32%), and in non-surgical ones 22/26 (86%; 95% CI: 65 to 96%) – 27 patients were alive on June 30, 2013, at median 120 months after SAH.

The 15 non-surgical patients denied aneurysm repair due to age were on the average 2 years older than the 96 surgical ones, with correspondingly fewer expected remaining life years (p = 0.04) – Nevertheless, their loss of expected life years from SAH exceeded the age difference: 2.6 years (p = 0.29).

At median 30 months after SAH, all 67 survivors (fluent in the Norwegian) were invited to participate in the study, and received self-assessment health status questionnaires by mail. The return rate was 91%. Of survivors, 73% considered their health as ‘good’, ‘very good’ or ‘excellent’; mars scores of 0, 1 and 2 were reported by 70%; 77% had ADEL-score ≥90; 77% reported living at home; whereas 78% used public transportation with or without aid.

Conclusion

Unless ruptured aneurysms are not repaired, the outlook is grim for individuals aged ≥70 years. Following repair, the outcome seems acceptable. We posit that individuals aged ≥70 years should not be denied aneurysm repair on grounds of chronological age alone.

Interv Neurol. 2014 Apr;2(2):49–96.

Endovascular Repair of the Ruptured Anterior Communication Artery Complex and Wide Neck Aneurysm

YM Lodi, VV Reddy, A Devasenapathy, A Swrankar, K Sethi, D Gaylon, S Bajwa

Introduction

Due to the presence a complex anatomical and a hemodynamic profile at the anterior communication artery (AComA), especially when both A2 segments originate from a single A1 segment of the anterior cerebral artery (ACA), a successful surgical or endovascular repair of AComA aneurysm does not always guarantee good outcome. Surgical clipping not only poses difficulties but also may induce spasm to the ACA leading to stroke despite a successful procedure. Therefore, more aneurysms in AComA are being treated with endovascular technique including complex and wide neck aneurysms.

Objective

Objective of our study is to report our experiences of endovascular repair of ruptured AComA aneurysms including wide neck and complex aneurysms.

Methods

From prospectively maintained aneurysm data base consecutive patients with the diagnosis of ruptured AComA aneurysms who underwent with endovascular coiling from July 2007 to July 2009 were enrolled. Patients’ demographics including Hunt and Hess (H&H) grade, fisher scale, procedure related complication and outcome were collected.

Results

54 patients with mean age of 52 ± 14 years old were diagnosed with AComA ruptured aneurysm underwent successful endovascular repair of their aneurysm 21/54 (49% wide neck and complex) in nature. History of hypertension was present in 30, smoking in 40, family history of stroke in 9 and prior stroke 1 patient. H&H V was present in 3 (5%), IV in 12 (22%), III in 16 (30%), II in 15 (28%) and I in 7 (13%). Fisher 4 was present in 25 (46%), 3 in 15 (28%), 2 in 6 (11%) and 1 in 9 (17%) of patients 28/51 (55%) required ventriculostomy catheter 18 (35.3%) before and 10 (19.6%) after the coiling procedure. Procedure related morbidity was observed in 3/54 (5.5%) without mortality or permanent disability. Intraoperative rupture of aneurysm as manifested by the extravasations on the angiogram without any clinical manifestations (dilated pupils or increased blood pressure) was observed in two wide neck cases which resolved with subsequent coils placement. First case was a 74 years old woman who presented with H&H II and Fisher 3 and achieved GOS 5. The second case was a 46 years old woman with H&H II and Fisher 4 who achieved GOS 4. Right middle cerebral artery occlusion was observed in a 56 years old woman during coiling who presented with H&H II and Fisher 4. The MCA was completely revascularized using 2 mg TPA and MERCI retrieval device. Post procedure examination was non-focal and achieved GOS 5 in 30 days. Complete obliteration of aneurysms was observed in 31 (57%) and near complete in 21 (39%) and subtotal in 2 cases (4%). 30 days good outcome was observed in 72% of cases (GOS 5 in 27 (50%), GOS 4 in 12 (22%), GOS 3 in 8 (15%) and poor outcome GOS 1 (dead) in 7 (13%). Poor outcome and disabilities was associated with high H&H grade.

Conclusions

Endovascular coiling to repair ruptured AComA could be offered in most of the cases including those with wide neck and complex in nature. The most common but challenges are intraoperative rupture of aneurysm and thromboembolic event, which could be successfully treated with good outcome.

Interv Neurol. 2014 Apr;2(2):49–96.

Single Balloon Microcatheter Technique for Coiling Wide Necked Aneurysms: A Case Series

Sonal Mehta, Connor J Einertson, Randall Edgell

Introduction

Coil embolization of wide necked cerebral aneurysms frequently requires the use of stents and temporary occlusion using non-detachable compliant balloons. The traditional technique of balloon assisted coiling involves the use of two microcatheters, which may be associated with greater thromboembolic complications. We describe a series of coil embolizations performed using a single microcatheter balloon technique to treat wide-necked aneurysms. In this technique the coils were delivered through a balloon microcatheter with a coaxial dual-lumen design with the balloon inflated at the aneurysm neck.

Methods

A retrospective chart review was performed to identify cases in which the Ascent balloon (Codman, Raynham, MA) was used for aneurysm coil embolization as a single balloon microcatheter. Clinical, demographic, angiographic data were obtained.

Results

Five cerebral aneurysms were treated using the single balloon microcatheter technique. Four of these were unruptured whereas one was ruptured. All aneurysms were large (maximum diameter 6 mm or greater), with an average maximum diameter of 7.8 mm, an average neck diameter of 3.5 mm, and average volume of 154.7 mm³. Complete occlusion with coil embolization (RROC I) was achieved in all cases. The average packing density was 42.44%. High PD (>22%) was achieved in 4 cases whereas moderate PD (12–22%) was achieved in one case.

Conclusion

This initial experience demonstrates the feasibility and immediate outcomes of a single balloon microcatheter technique in coil embolization of wide-neck cerebral aneurysms. This technique may be used to achieve high packing density while avoiding permanent stent placement and potentially reducing thromboembolic complications.

Interv Neurol. 2014 Apr;2(2):49–96.

Meta-Analysis of Reversible Cerebrovascular Vasoconstriction Syndrome Without Subarachnoid or Intracerebral Hemorrhage

Ghulam Mustafa, Aman Dabir, Haris Kamal, Mufti Owais, Ping Li, Mohammed Shafie, Han Lee, Aaron McMurtray, Bijal K Mehta

Background

Reversible vasoconstriction syndrome is a phenomenon where the vasculature of the brain begins to spasm. Although initially thought to be only associated with intracranial and subarachnoid hemorrhage, recently, this has expanded to include non-hemorrhagic states. The etiology and physiology of this type of reversible vasoconstriction syndrome remains to be worked out.

Methods

Our meta-analysis will discuss the demographic, past medical and concurrent medical history, and imaging characteristics, including CT and conventional angiograms of non-hemorrhagic cases in the literature. This includes prior studies and cases/case series where data of non-hemorrhagic cases where vasospasm was noted. A review of treatments, including endovascular approaches, will also be discussed.

Results

Similarities and differences from reversible vasoconstriction syndrome associated with hemorrhage will be noted. A discussion of how patients with non-hemorrhagic reversible vasoconstriction syndrome are managed.

Conclusion

Reversible vasoconstriction syndrome may present differently in patients without associated subarachnoid or intracranial hemorrhage.

Interv Neurol. 2014 Apr;2(2):49–96.

Effect of Clot Characteristics on Successful Recanalization with the Solitaire FR Stent Retriever Device in Acute Ischemic Stroke

Maxim Mokin, Simon Morr, Kenneth Snyder, Elad Levy, Adnan Siddiqui

Background

Several studies have addressed the association between thrombus characteristics and efficacy of intravenous and intraarterial revascularization strategies. Current data regarding the value of clot length and Hounsefield unit measurements in predicting successful revascularization with mechanical thrombectomy devices in strokes due to large vessel occlusion are controversial.

Methods

We retrospeci vely reviewed cases of acute ischemic stroke duet o large vessel occlusion (ICA terminus, M1, M2, basilar) treated with Solitair FR stent retriever. We collected data on thrombus location, length, Hounsefield unit values, and clot burden score. Their association with successful revascularization (defined as TICI 2B or 3) was analyzed using Student's T and Wilcoxon tests as appropriate.

Results

We identified a total of 54 patients. No significant difference was found between clot length, location, or average Hounsefield unit values in cases with successful recanalization compared to those without.

Conclusion

Our data do not support the use of clot length and Hounsefield unit values in the acute decision making process in the setting of acute large vessel occlusion strokes.

Interv Neurol. 2014 Apr;2(2):49–96.

Stenting and Angioplasty of Small Cerebral Arteries in Symptomatic Intracranial Atherosclerotic Disease

Emad Nourollah-Zadeh, Alicia Castonguay, Junaid Kalia, Brian-Fred Fitzsimmons, Marc Lazzaro, John Lynch, Osama O Zaidat

Background

Intracranial atherosclerotic disease (ICAD) is a common cause of stroke with poor natural history despite medical therapy. Symptomatic ICAD in distal intracranial arteries is a poorly studied topic. In medically refractory patients, alternative treatment includes angioplasty with or without stenting; here we characterize feasibility and safety of using these endovascular interventions.

Method

We reviewed personal logs and financial data information to identify patients who were treated for small artery ICAD (stenosis >50%) using angioplasty ± stenting. Small cerebral artery was defined by diameter ≤2 mm or any of branches distal to large intracranial vessels (i.e. distal to ICA, M1, A1, Vertebrobasilar trunk). Patient characteristics, clinical manifestation, treatment, hospital course and follow up data were collected and analyzed.

Results

Ten patients (12 arteries) were treated with either primary balloon angioplasty (58.3%) or angioplasty with stenting (41.6%) with 100% technical success rate. Mean pre-treatment stenosis was 79.9% while mean post-treatment stenosis was 19.0%. There were no major peri-procedural complications including symptomatic intracranial hemorrhage or mortality; three patients had stable groin hematoma. Patients were followed for mean total of 18.6 months with only one symptomatic restenosis following a primary angioplasty that was re-treated successfully with stenting. All patients had good functional outcome with mRS of either 0 (80%) or 1 (20%) during the follow up.

Table 1.

Summary of characteristics, stenosis, treatment and follow up in patients with small artery intracranial atherosclerotic disease

Case #	Age/Sex	Comorbidity	Site	Stenosis (%)		Time of onset to Tx	Balloon (mm)	Stent	Complication	Last follow up		Aspirin + Plavix duration
Case #	Age/Sex	Comorbidity	Site	Pre-	Post-	Time of onset to Tx	Balloon (mm)	Stent	Complication	Imaging	Clinical	Aspirin + Plavix duration
1	64/M	HTN, HLD	P2	80	10	3 days	Gateway 2 × 9	WS 3.5 × 15	None	11 months, patent with intimal hyperplasia	11 months, mRS 0	3 days, Plavix & Warfarin

2.1	85/F	HTN, TIA	A3	99	10	1 month	Gateway 1.5 × 9	None	None	2 months, 95% re-stenosis	2 months, mRS 1 (intermittent Sx)	Indefinite

2.2	85/F	HTN, TIA	A3	99	10	2 months	Gateway 2.5 × 15	WS 3.5 × 9	None	1 month, patent	12 months, mRS 0	Indefinite

3	65/F	HTN, HLD, CAD, Stroke	P2	67	14	3 months	Gateway 2.5 × 15	WS 3 × 15	None	68 months, patent	68 months, mRS 0	Indefinite

4	56/M	HTN, HLD, CAD, TIA	A3	55	20	1 month	Gateway 2 × 9	None	None	1 month, patent	33 months, mRS 1	3 days, Aspirin only

5.1	38/F	HTN, DM, HLD, CAD, Stroke	P2	95	20	2 weeks	Gateway 2 × 15	None	Groin Hematoma	14 months, <50% restenosis	14 months, mRS 0	Indefinite

5.2	38/F	HTN, DM, HLD, CAD, Stroke	P2	55	20	2 weeks	Gateway 15 × 15	None	Groin Hematoma	14 months, <50% restenosis	14 months, mRS 0	Indefinite

6	76/F	HTN, DM, HLD, TIA	A2	80	20	4 months	Maverick 1.5 × 9	None	None	None	2 months, mRS 0	2 months (Plavix daily)

								15		hyperplasia

8	75/F	HTN, HLD, TIA	PIC A	75	20	6 months	Gateway 2 × 9	None	Groin Hematoma	5 months, patent	5 months, mRS 0	3 months (Aspirin daily)

9	75/M	HLD	M2/M3	99	30	3 days	Maverick 1.5 × 9	None	None	21 months, <50% re-stenosis	22 months, mRS 0	Indefinite

10	49/M	HTN, HLD, TIA	P2	80	35	1 month	Gateway 1.5 × 15	WS 3 × 15	None	11 months, 45% restenosis	11 months, mRS 0	Indefinite

Open in a new tab

CAD = Coronary artery disease; DM = diabetes mellitus; HLD = hyperlipidemia; HTN = hypertension; TIA = transient ischemic attack; WS = wingspan.

Conclusion

In our case series, treatment of symptomatic small artery ICAD with angioplasty ± stenting was safe and effective. These interventions should be considered as an alternative in patients refractory to medical therapy.

Interv Neurol. 2014 Apr;2(2):49–96.

Comparison of Large Vessel Stroke Patient Outcomes Before and After Initiation of On-Site Endovascular Stroke Treatment Services

Yamin Shwe, Santiago Ortega-Gutierrez, Ahmed Otokiti, Srikar Jonna, David Altschul, Srinivasan Paramasivam, Alejandro Berenstein, Johanna T Fifi

Rational

Availability of an on-site endovascular program for large vessel stroke decreases the time to acute treatment. Since expanding our program to a Manhattan hospital in July 2009, we have seen a decreased time to treatment. We hypothesize that the expansion was associated with improved discharge outcomes in patients with anterior circulation large vessel strokes.

Methods

A retrospective chart review of consecutive patients before and after the initiation of the program was conducted. Adults presenting to the hospital with an NIHSS greater than 8, within 6 hours from stroke onset, and with carotid terminus or middle cerebral artery occlusion were included. Exclusion criteria were INR or creatinine >3 and premorbid modified Rankin score (MRS) >1. Comparison was made between the groups before and after initiation of the program. MRS, disposition, mortality and MRI stroke volume were selected as discharge outcomes. Logistic regression was performed and p < 0.05 being statistically significant.

Results

70 patients were included in the study. 30 were admitted before July 2009 and 40 after. There was no difference between patient demographics. Only 3/30 patient received endovascular treatment prior to July 2009 versus 34/40 after that. Patients admitted after availability of on-site endovascular treatment were less likely to be dependent (OR: 0.14; 95% CI: 0.019–1) or discharged other than home (OR: 0.233; 95% CI: 0.062–0.876) after adjusting for age and admission NIHSS. In addition there was a significant increase in median admission-discharge NIHSS change in patients treated after July 2009 (p = 0.007).

Discussion

For every 30 minutes until reperfusion, the probability of good recovery after a large vessel stroke is decreased by about 10%. Transfer delays may impede or limit the benefit of endovascular recanalization. In the absence of strategic air transportation systems, rapid deployment of an endovascular team might decrease the time to recanalization and improve patient outcomes.

Interv Neurol. 2014 Apr;2(2):49–96.

Single-Center Retrospective Experience with Stentrievers in Acute Ischemic Stroke Treatment

Pankajavalli Ramakrishnan, Chung-Huan J Sun, Michael R Frankel, Aaron M Anderson, Sameer R Belagaje, Fadi Nahab, Rishi Gupta, Raul Nogueira

Introduction

Stentrievers have been approved by the FDA for use in mechanical thrombectomy in the treatment of acute ischemic stroke. High rates of successful reperfusion and improved clinical outcomes using these devices in randomized clinical trials have provided the impetus for supplanting the older generation thrombectomy devices. We present a single-center, retrospective analysis of mechanical thrombectomy with Solitaire FR, and Trevo stentrievers in 202 patients.

Methods

Between June 2011 and August 2013, Solitaire FR or Trevo stentrievers were used in 202 consecutive acute ischemic stroke cases.

Results

Average age of this cohort was 66.7 years with a mean NIHSS of 18.7. 53% received iv tPA before proceeding to IA treatment with stentrievers. ASPECT score was 7 or better in 73%. Solitaire FR or Trevo was the only stentriever used in 54.5%, and 39.1%, respectively, and both were used in 6.4%. The mean duration from last known well to reperfusion was 401.4 minutes. The average time from groin puncture to reperfusion was 76.3 minutes. TICI 2B or better reperfusion rates were achieved in 88.6%. PH1, and PH2 hemorrhagic transformation were noted in 6.5% and 4.5%, respectively. 90 day mRS scores are available for 134 patients as of this submission, and were highly dependent on age, baseline NIHSS, and ASPECT score: mRS of 0-2 in 35.8% (n = 48/134), and mRS of 0-3 in 48.5% (n = 65/134).

Conclusion

Stentrievers can be a powerful tool in achieving high rates of successful reperfusion inacute ischemic stroke.

Interv Neurol. 2014 Apr;2(2):49–96.

Geographical Location and Transfer Circuits in Acute Stroke Patients Candidates for Endovascular Therapies

Marc Ribo

Introduction

Geographic location may challenge access to endovascular therapies for acute ischemic stroke. Primary transferring potential candidates to centers not offering these therapies may incur in considerable delays. We aimed to study time delays at different points in stroke patients that received endovascular procedures.

Methods

Observational, population-based study of consecutive AIS patients treated with any reperfusion modality within 2011 and 2012 in Catalonia (7.5 M inhabitants).

Patients were prospectively included in a health-administration based register with external monitoring of completeness. Inclusion criteria: all patients that received acute endovascular procedures in Comprehensive Stroke Centers (H2), either transferred (TR) from an initial hospital (H1) or primary (PR) admitted to H2.

Results

571 patients received endovascular treatment, of them 284 received ivTPA before. 208 patients (TR) were initially admitted in H1 and transferred to H2. Mean distance between H1 to H2 was 70 (±20) km.

There were no major baseline clinical differences between TR and PR patients. Median time from symptom onset to first admission hospital was (H1: 77 min vs. H2: 100 min; p = 0.25). TR patients had a significantly longer time from symptom-to-groin puncture (TR 320 vs. PR 240 minutes; p < 0.01).

For TR patients, median time from H1-door to H2-door was 185 minutes (IQR 141-217) minutes. Among the 208 TR patients, only 117 (56.3%) received iv-tPA at H1. In the remaining 91 TR patients main predictors of no iv-tPA treatment were: H1 admission >4.5 hours from symptom onset (89%) and being on anticoagulants (82%).

Conclusion

In acute stroke patients receiving endovascular treatment, inter-hospital transfers may represent a substantial time delay. Clinical algorithms to save time or detect patients who will not benefit from admission in hospitals unable to offer endovascular therapies should be investigated.

Interv Neurol. 2014 Apr;2(2):49–96.

Stenting of Symptomatic Extracranial Vertebral Artery Occlusions

Christopher Streib, Nima Aghaebrahim, Srikant Rangaraju, Ashutosh Jadhav, Brian Jankowitz, Tudor Jovin

Introduction

Bilateral vertebral artery disease can lead to refractory vertebrobasilar insufficiency (VBI). Historically, outcomes in this patient population are poor and optimal treatment remains unclear. The purpose of this study was to assess whether endovascular recanalization of extracranial vertebral artery occlusions (EVAOs) in select patients with VBI led to improved outcomes.

Methods

In a retrospective analysis of a prospectively collected cohort of patients treated at our center between 2006–2013, we identified patients with VBI secondary to bilateral EVAOs or unilateral EVAO plus contralateral hypoplastic vertebral artery. Six patients who met the aforementioned criteria were treated endovascularly with angioplasty and stenting of an EVAO.

Results

In our series, all six patients were successfully recanalized. Four patients (66%) had a good clinical outcome (mRS 0-2); three had an mRS = 0 at their most recent follow-up (range: 3 months-7 years post-procedure). Two patients (33%) died (brainstem infarct (1), cardiac arrest (1)).

All patients were male between ages 49–63. Two patients had bilateral EVAOs, four patients had an EVAO and a contralateral hypoplastic vertebral artery. Locations of treated vertebral artery occlusions included V1 (3), V2 (1), V3 (2). Indications for treatment included: progressive posterior circulation strokes (4), recurrent TIAs (1), and radiographic evidence of poor collateralization (1).

Conclusion

The dichotomy of our results likely reflects both the severity of the disease process as well as the potential for good outcomes. Recanalization of extracranial vertebral artery occlusions should be considered for carefully selected patients presenting with VBI secondary to bilateral vertebral artery disease.

Interv Neurol. 2014 Apr;2(2):49–96.

Implementation of an ED-Based Rapid Brain-Attack Triage Algorithm in a Regional Tele-Stroke Network Positively Impacts Treatment Rates for Acute Ischemic Stroke

Background

A simplified algorithm for evaluating and triaging brain-attack patients in the emergency department (ED) similar to heart-attack patients can potentially improve treatment rates.

Methods

A simplified 2-step ED-based Rapid Brain-Attack Triage Algorithm was developed as part of our stroke network. The first step includes a non-contrast head CT to distinguish a hemorrhagic stroke from an ischemic stroke. The second step includes identifying the ‘last known normal (LKN)’. The Texas Stroke Institute Rapid Brain-Attack Triage Algorithm was implemented for all Tele-stroke consultations within the regional stroke network. Data was prospectively collected from January 2012 August 2013.

Results

A total of 1,763 Tele-stroke consultations were performed either via the Telephone or via the Camera. The majority of them were stroke patients (1,279/1,763; 73%) and 21% were hemorrhagic stroke patients (370/1,763). Among the ischemic stroke patients, 56% (711/1,279) presented within 12 hours from LKN and 41% (294/711) received either intravenous r-tPA and/or catheter based mechanical thrombectomy.

Conclusion

A simplified ED-based Rapid Brain-Attack Triage Algorithm as part of a regional Tele-stroke Network is feasible and increases treatments rates in patients with acute ischemic stroke.

Interv Neurol. 2014 Apr;2(2):49–96.

Cost Efficiency and Follow-Up Data Using the Penumbra Coil 400 for Treatment of Aneurysms in the Cerebrovascular System

G Vidal, J Milburn, A Pansara, R Martinez

Purpose

This study was designed to compare the cost effectiveness and treatment stability of the larger diameter Penumbra Coil 400 with the commonly used smaller diameter Orbit/Galaxy coil.

Methods

In a retrospective single center study, 18 consecutive aneurysms treated using the Penumbra coil were compared to 40 treated with Orbit or Galaxy coils from 2010 to February 2012. Aneurysm occlusions based on the Raymond Scale at the time of initial treatment were compared with follow-up studies to evaluate coil stability.

Results

Number of coils per aneurysm volume was 0.026 coil/mm³ for Penumbra. This was significantly less than 0.114 coil/mm³ for Orbit/Galaxy. Average packing density of 33.7% for Penumbra was significantly greater than 24.4% for Orbit/Galaxy. Aneurysm occlusion rates at the time of treatment were similar in the 2 groups. Cost analysis estimated a 67% reduced cost for Penumbra coils per volume of aneurysm. Follow-up was available on 14 of the 18 Penumbra aneurysms with an average time of 9.6 months, and stability or improved obliteration was noted in 13. There was one coil migration into mural thrombus which was retreated with additional coiling. Follow-up studies on 25 of the 40 aneurysms treated with Orbit/Galaxy averaging 11.4 months showed stability or improvement in 21. There were 4 that had a worse Raymond class, and one was retreated with stent-coiling.

Conclusions

Aneurysm treatment using the Penumbra Coil 400 results in higher packing density compared to Orbit/Galaxy. The Penumbra coil is more cost effective, and follow-up studies suggest durable occlusions.

Interv Neurol. 2014 Apr;2(2):49–96.

Background

Our aim was to determine if stentriever treatment results in cost effectiveness over Merci thrombectomy and to identify a cost-effective imaging threshold for intra-arterial treatment selection.

Methods

With institutional approval, we retrospectively reviewed patients undergoing intra-arterial stroke therapy from March 2011 to March 2013 at our center. We collected the following data: stroke score, occlusion site, baseline Alberta Stroke Program Early CT Score (ASPECTS), device used, reperfusion, hemorrhage, 90-day modified Rankin Score (mRS), and procedure cost. Using published criteria, a quality-adjusted life year (QUALY) value of 0.74 and 0.4 was ascribed to a mRS outcome ≤2 and >2 respectively. Using the procedural mean cost, we calculated an incremental cost efficiency ratio (ICER) for stentriever versus Merci embolectomy and for interventions done for a baseline ASPECTS above and below the following thresholds: >6, >7, >8, and >9. Using established criteria, we identified a cost effective patient selection if the ICER was positive and less than $50,000/QUALY.

Results

Our cohort included 122 patients, 45 treated with Merci in the first year and 78 with stentrievers in year two. Reperfusion occurred in 79% (87% in the stentriever and 64% with Merci groups, p = 0.002). The good outcome rate for the entire cohort was 40% (43% good outcomes in the stentriever and 33% in the Merci groups, p = 0.21) respectively. Stentriever interventions were not cost effective compared to Merci embolectomy (ICER >$500,000/QUALY). Using baseline ASPECTS >6 and >7 as a selection criteria for intervention, the good outcome rate was 42% and 44% respectively but with a negative ICER due to higher costs in treating those with lower scores. For those with an ASPECTS >8 and >9, the good outcome rate was 44% and 54% with an ICER of $40,000/QUALY and $24,000/QUALY respectively.

Conclusions

At our institution, despite better outcome and reperfusion rates, stentriever interventions are yet to show a cost benefit. Optimizing patient selection by using the ASPECTS scoring system has led to improved clinical outcomes and cost effectiveness. Further prospective study may validate this technique for greater value to the individual patient and the health system at large.

Interv Neurol. 2014 Apr;2(2):49–96.

Author Index

Numbers refers to page number

Aghaebrahim, A. 57

Aghaebrahim, N. 92

Altschul, D. 89

Amorim, E. 57, 79

Anderson, A.M. 78, 90

Arcot, K.M. 76

Azhar, S. 76

Aziz-Sultan, M. 71

Bajwa, S. 81

Bakke, S.J. 80

Belagaje, S.R. 78, 90

Berenstein, A. 89

Bhuva, P. 58, 93

Britz, G. 69

Budzik, R. 95

Carlson, L. 58

Case, D. 59

Castonguay, A. 85

Chen, S. 60

Chen, S.H. 93

Coffman, S.R. 60

Connors, J. 61

Cortez, V. 62, 65

Coulson, J. 58, 68, 70

Dabir, A. 83

Dash, S. 76

Dávalos, A. 66

Davis, T. 95

Delbrune, J. 76

Devasenapathy, A. 81

Edgell, R. 82

Einertson, C.J. 82

Elhammady, M. 71

Farkas, J. 76

Fifi, J. 67

Fifi, J.T. 89

Fitzsimmons, B.-F. 85

Frankel, M.R. 78, 90

Gamber, M. 60

Garg, A. 74, 75

Gaylon, D. 81

Gaynor, B. 71

Gianatasio, R. 60, 68, 70, 93

Gokhale, S. 69

Grandhi, R. 79

Gupta, R. 77, 78, 90, 95

Guthmann, A. 68, 93

Hansen, P.A. 70, 93

Hartman, W.T. 60

Haussen, D. 71

Hicks, B.J. 95

Higashimori, T. 59, 72

Hoover, S. 74, 75

Jadhav, A. 79, 92

Jadhav, A.P. 57

Janardhan, V. 58, 60, 68, 70, 93

Janjua, N. 76

Jankowitz, B. 57, 79, 92

Johnson, J. 71

Jonna, S. 89

Jovin, T. 57, 79, 92

Jumaa, M. 57

Kalia, J. 85

Kamal, H. 83

Kass-Hout, O. 77, 78

Kass-Hout, T. 77, 78

Kenmuir, C. 79

Khan, S. 69

Kumar, R. 76

Kumpe, D. 72

Lazzaro, M. 85

Lee, H. 83

Leiva-Salinas, C. 57

Levin, K.A. 76

Levy, E. 84

Li, P. 83

Linares, G. 79

Lindegaard, K.-F. 80

Lodi, Y.M. 81

Lynch, J. 85

Margulis, Y. 76

Martinez, R. 94

McDonagh, D. 69

McMurtray, A. 83

Mehta, B.K. 83

Mehta, S. 82

Mejilla, J. 95

Milburn, J. 94

Mokin, M. 84

Morr, S. 84

Murray, M.M. 93

Mustafa, G. 83

Myers, J.H. 60

Nahab, F. 77, 90

Nogueira, R. 77, 90

Nogueira, R.G. 78

Nourollah-Zadeh, E. 85

Ortega-Gutierrez, S. 89

Otokiti, A. 89

Owais, M. 83

Pandhi, A. 58, 60, 68, 70, 93

Pansara, A. 94

Papamitsakis, N. 76

Paramasivam, S. 89

Pema, P. 95

Peterson, E. 71

Phillips, K.D. 58

Polderman, K. 79

Ramakrishnan, P. 90

Ramakrishnan, V. 65

Rangaraju, S. 92

Reddy, V.V. 81

Reese, B. 95

Ribo, M. 91

Robbins, S. 58, 68, 70

Roland, A. 70

Roper, D. 58, 68, 70, 93

Safavi-Abbasi, S. 74, 75

Saucedo, S. 74, 75

Seinfeld, J. 59

Sethi, K. 81

Shafie, M. 83

Shwe, Y. 89

Siddiqi, J. 62

Siddiqui, A. 84

Snyder, K. 84

Sodhi, A. 65

Sorteberg, W. 80

Stands, K. 95

Streib, C. 92

Sun, C.-H.J. 90

Sun, C.H. 77, 78

Swrankar, A. 81

Tafish, I. 75

Taqi, M. 62, 65

Urra, X. 57

Venizelos, A. 58, 60, 68, 70, 93

Vidal, G. 94

Vora, N. 95

Walzman, D.E. 76

Wechsler, L. 79

Whitely, M. 58

Whitley, M. 68, 93

Wintermark, M. 57

Wolfe, T. 65

Yavagal, D. 71

Young, S. 95

Zaidat, O.O. 85

Zaidi, S. 57

Zhu, G. 57

PERMALINK

6th Annual Meeting of the Society of Vascular and Interventional Neurology

Outcomes After Endovascular Treatment for Anterior Circulation Stroke Presenting as Wake-Up Strokes Are Not Different Than Those with Witnessed Onset Beyond 8 hours

Amin Aghaebrahim

Carlos Leiva-Salinas

Syed Zaidi

Mouhammad Jumaa

Xabi Urra

Edilberto Amorim

Guangming Zhu

Ashutosh P Jadhav

Brian Jankowitz

Max Wintermark

Tudor Jovin

Objective

Methods

Results

Conclusion

Use of Standardized Protocols and Order Sets at a Comprehensive Stroke Center Decreases the Average Hospital Length of Stay for Patients with Non-Traumatic Intracerebral Hemorrhage (ICH)

Parita Bhuva

Kyloni D Phillips

Alexander Venizelos

Debbie Roper

Jeff Coulson

Lauren Carlson

Scott Robbins

Mark Whitely

Abhi Pandhi

Vallabh Janardhan

Background

Methods

Results

Conclusion

Endovascular Treatment of Distal PICA Aneurysms Associated with AVMs

David Case

Taka Higashimori

Joshua Seinfeld

Conclusions

Fig. 1.

Texas Stroke Intervention Pre-Hospital Stroke Severity Scale (aka LEGS score): A Novel Triaging Tool for Interventional Stroke Therapy

Sherman Chen

Alexander Venizelos

Abhi Pandhi

Ryan Gianatasio

Stewart R Coffman

Mark Gamber

W Tim Hartman

John H Myers

Vallabh Janardhan

Background

Methods

Results

Conclusion

Current Risk-Adjusted Clinical Outcomes from the INterventional Stroke Therapy Outcomes Registry

John Connors

Introduction

Methods

Results

Conclusion

Complexity of Treatment for PICA Aneurysm: A Case Series and Review of Literature

Vladimir Cortez

Muhammed Taqi

Javed Siddiqi

Case 1

Fig. 1.

Case 2

Fig. 2.

Case 3

Fig. 3.

Increase Incidence of Aneurysmal Rupture Less Than 5 mm

Vladimir Cortez

Ajeet Sodhi

Vivek Ramakrishnan

Muhammed Taqi

Thomas Wolfe

Solitaire FR Thrombectomy for Acute Revascularization (STAR) Study in Patients with Acute Ischemic Anterior Circulation Stroke: Subgroup Analyses

Antoni Dávalos

Background

Methods

Findings