risk of ipsilateral stroke was 25.3% in the medically treated patients and 16.0% in the surgically treated patients. 2 , 4 The greatest technical risk of CEA in this setting is disruption of the thrombus during exposure of the CCA and ICA. Before the advent of distal embolic protection, stent placement for symptomatic CA lesions containing intraluminal thrombus required crossing the lesion without protection against distal release of emboli. Now devices for distal embolic protection, reversal of flow, and proximal protection by flow arrest are available for
Report of two cases
Robert D. Ecker, Ramachandra P. Tummala, Elad I. Levy and L. Nelson Hopkins
Robert D. Ecker, Tsz Lau, Elad I. Levy and L. Nelson Hopkins
) symptomatic patients with more than 70% CA stenosis. 11 , 12 Payments for devices and associated procedures are determined by the CMS after FDA approval. The current CMS coverage decision (as of March 17, 2005) allows for reimbursement of CAS treatment costs only in patients with symptomatic stenosis greater than or equal to 70% or for patients enrolled in FDA-sponsored clinical trials. With that coverage decision, CAS placement finally earned legitimacy as a treatment alternative to CEA. Unlike CEA, however, which has a clearly defined 30-day morbidity/mortality rate
Elad I. Levy, Adnan H. Siddiqui and L. Nelson Hopkins
high rate of recurrent stroke. 4 This has resulted in reinvigoration of endovascular strategies for revascularization of intracranial stenoses. 8 , 9 , 11 , 14 , 21 , 23 , 24 , 26 There are an increasing number of devices specifically designed to meet the challenges of an inhospitable intracranial vasculature and that may be useful for the treatment of intracranial stenoses. The Stenting vs Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Vitesse Intracranial Stent Study for Ischemic Therapy trials are underway to explore
R. Loch Macdonald
O ne of the few groups investigating intracranial aneurysm hemodynamics reports in silico modeling of changes in computational fluid dynamics (CFD) of cerebral aneurysms after treatment with flow-diverting stents. 7 The authors describe 3 patients with intracranial aneurysms treated with flow-diverting Pipeline Embolization Devices (PEDs). They calculated aneurysm flow velocity, inflow rate, wall shear stress ([WSS]; a measure of change in flow into the aneurysm) and turnover time (a measure of stasis in the aneurysm) before and after placement of the PED
J Mocco, Ricardo A. Hanel, Jitendra Sharma, Erik F. Hauck, Kenneth V. Snyder, Sabareesh K. Natarajan, Italo Linfante, Adnan H. Siddiqui, L. Nelson Hopkins, Alan S. Boulos and Elad I. Levy
used similar stent systems with comparable technical profiles and delivery systems, manufactured by the same company (Wingspan and Neuroform stent systems, Boston Scientific). The Wingspan system is intended for intracranial stenosis treatment and the Neuroform system for aneurysm neck reconstruction. Recently, a new self-expanding stent has become available to the endovascular community, the Enterprise Vascular Reconstruction Device (Codman Neurovascular/Cordis Corp.). This device uses a catheter-based delivery system that has been suggested to provide improved
Kunal Vakharia, Stephan A. Munich, Muhammad Waqas, Swetadri Vasan Setlur Nagesh and Elad I. Levy
Progressive deconstruction with flow diversion using a Pipeline embolization device (PED; Medtronic) can be utilized to promote thrombosis of broad-based fusiform aneurysms. Current flow diverters require a 0.027-inch microcatheter for deployment. The authors present a patient with a fusiform P2–3 junction posterior cerebral artery aneurysm in which they demonstrate the importance of haptics in microwire manipulation to recognize large-vessel anatomy versus perforator anatomy that may overlap, especially when access is needed in distal tortuous circulations. In addition, the authors demonstrate the need for appropriate visualization before PED deployment. Postembolization runs demonstrated optimal wall apposition with contrast stasis within the aneurysm dome.
The video can be found here: https://youtu.be/8kfsSvN3XqM.
Elad I. Levy, Stephan A. Munich, Robert H. Rosenwasser, Peter Kan and B. Gregory Thompson
Remarkable developments in the field of endovascular neurosurgery have been witnessed in the last decade. The success of endovascular therapy for ischemic stroke treatment is now irrefutable, making it an accepted standard of care. Endovascular treatment of cerebral aneurysms is no longer limited to primary coiling but now includes options such as stent or balloon assistance and flow diversion and applications utilizing neck reconstruction, intrasaccular, and bifurcation-specific devices. Balloons, liquid embolic agents, and flow-directed catheters have revolutionized the treatment of arteriovenous malformations and fistulae. The ongoing development of endovascular tools has led to novel and expanding approaches (for example, transvenous arteriovenous malformation embolization and transradial access). With improved technology, transposterior communicating artery access and other endovascular strategies are being applied successfully across the anterior and posterior circulations and to lesions once deemed only surgically approachable. Yet, we would be remiss to attribute the successes of endovascular strategies only to the development of their tools. Improvements in both noninvasive and angiographic imaging (such as three-dimensional road map guidance) have provided a greater understanding of pathologic entities and allowed the pursuit of endovascular cures.
In this issue of Neurosurgical Focus, we present a wide range of endovascular strategies for a variety of neurovascular pathologies. We hope this video supplement will not only demonstrate the applicability of tried-and-true endovascular strategies to difficult clinical situations but also highlight new and developing endovascular technologies. We thank the authors for their outstanding contributions.
Mandy J. Binning, Alexander A. Khalessi, Adnan H. Siddiqui, L. Nelson Hopkins and Elad I. Levy
critical first step in what may prove a promising line of inquiry: stent placement for the treatment of traumatic intracranial dissections in children. Disclosure Dr. Hopkins receives research study grants from Abbott (ACT 1 Choice), Boston Scientific (CABANA), Cordis (SAPPHIRE WW), and ev3 (CREATE) and a research grant from Toshiba (for the Toshiba Stroke Research Center); receives royalties from Cordis (for the Angioguard device); has an ownership/financial interest in AccessClosure, Boston Scientific, Micrus, and Valor Medical; serves on the Abbott Vascular
Daniel H. Sahlein, Mohammad Fouladvand, Tibor Becske, Isil Saatci, Cameron G. McDougall, István Szikora, Giuseppe Lanzino, Christopher J. Moran, Henry H. Woo, Demetrius K. Lopes, Aaron L. Berez, Daniel J. Cher, Adnan H. Siddiqui, Elad I. Levy, Felipe C. Albuquerque, David J. Fiorella, Zsolt Berentei, Miklos Marosfoi, Saruhan H. Cekirge, David F. Kallmes and Peter K. Nelson
“ophthalmoparesis” should be grouped with subjective findings such as “diplopia.” In April 2011, the Pipeline Embolization Device (PED, Covidien) received FDA clearance for the endovascular reconstruction of large and giant wide-necked aneurysms of the ICA. The safety and efficacy of the PED has been unequivocally demonstrated for these aneurysms of the cavernous and supraclinoid segments of the ICA. 2 , 10 Although the treatment of large and giant ICA aneurysms with mass-occupying coils is very frequently associated with negative neuroophthalmological outcomes 17 —observed
Jianping Xiang, Robert J. Damiano, Ning Lin, Kenneth V. Snyder, Adnan H. Siddiqui, Elad I. Levy and Hui Meng
T he prevalence of intracranial aneurysms is estimated to be 1%–5% in the general population. 19 , 20 Aneurysm rupture leads to subarachnoid hemorrhage, and can result in devastating morbidity and mortality as well as high health care costs. 20 Flow diversion via flow diverters (FDs) such as the Pipeline Embolization Device (PED, Covidien) is a novel therapeutic method for the treatment of complex intracranial aneurysms, which can be challenging for both conventional microsurgical and endovascular techniques. The PED is a self-expandable, braided, mesh