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Purvee D. Patel, Nohra Chalouhi, Elias Atallah, Stavropoula Tjoumakaris, David Hasan, Hekmat Zarzour, Robert Rosenwasser and Pascal Jabbour

The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.

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Kate A. Hentschel, Badih Daou, Nohra Chalouhi, Robert M. Starke, Shannon Clark, Ashish Gandhe, Pascal Jabbour, Robert Rosenwasser and Stavropoula Tjoumakaris

OBJECTIVE

Mechanical thrombectomy is standard of care for the treatment of acute ischemic stroke. However, limited data are available from assessment of outcomes of FDA-approved devices. The objective of this study is to compare clinical outcomes, efficacy, and safety of non–stent retriever and stent retriever thrombectomy devices.

METHODS

Between January 2008 and June 2014, 166 patients treated at Jefferson Hospital for Neuroscience for acute ischemic stroke with mechanical thrombectomy using Merci, Penumbra, Solitaire, or Trevo devices were retrospectively reviewed. Primary outcomes included 90-day modified Rankin Scale (mRS) score, recanalization rate (thrombolysis in cerebral infarction [TICI score]), and incidence of symptomatic intracranial hemorrhages (ICHs). Univariate analysis and multivariate logistic regression determined predictors of mRS Score 3–6, mortality, and TICI Score 3.

RESULTS

A total of 99 patients were treated with non–stent retriever devices (Merci and Penumbra) and 67 with stent retrievers (Solitaire and Trevo). Stent retrievers yielded lower 90-day NIH Stroke Scale scores and higher rates of 90-day mRS scores ≤ 2 (22.54% [non–stent retriever] vs 61.67% [stent retriever]; p < 0.001), TICI Score 2b–3 recanalization rates (79.80% [non–stent retriever] vs 97.01% [stent retriever]; p < 0.001), percentage of parenchyma salvaged, and discharge rates to home/rehabilitation. The overall incidence of ICH was also significantly lower (40.40% [non–stent retriever] vs 13.43% [stent retriever]; p = 0.002), with a trend toward lower 90-day mortality. Use of non–stent retriever devices was an independent predictor of mRS Scores 3–6 (p = 0.002), while use of stent retrievers was an independent predictor of TICI Score 3 (p < 0.001).

CONCLUSIONS

Stent retriever mechanical thrombectomy devices achieve higher recanalization rates than non–stent retriever devices in acute ischemic stroke with improved clinical and radiographic outcomes and safety.

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Nohra Chalouhi, Badih Daou, Toshimasa Okabe, Robert M. Starke, Richard Dalyai, Cory D. Bovenzi, Eliza Claire Anderson, Guilherme Barros, Adam Reese, Pascal Jabbour, Stavropoula Tjoumakaris, Robert Rosenwasser, Walter K. Kraft and Fred Rincon

OBJECTIVE

Cerebral vasospasm (cVSP) is a frequent complication of aneurysmal subarachnoid hemorrhage (aSAH), with a significant impact on outcome. Beta blockers (BBs) may blunt the sympathetic effect and catecholamine surge associated with ruptured cerebral aneurysms and prevent cardiac dysfunction. The purpose of this study was to investigate the association between preadmission BB therapy and cVSP, cardiac dysfunction, and in-hospital mortality following aSAH.

METHODS

This was a retrospective cohort study of patients with aSAH who were treated at a tertiary high-volume neurovascular referral center. The exposure was defined as any preadmission BB therapy. The primary outcome was cVSP assessed by serial transcranial Doppler with any mean flow velocity ≥ 120 cm/sec and/or need for endovascular intervention for medically refractory cVSP. Secondary outcomes were cardiac dysfunction (defined as cardiac troponin-I elevation > 0.05 μg/L, low left ventricular ejection fraction [LVEF] < 40%, or LV wall motion abnormalities [LVWMA]) and in-hospital mortality.

RESULTS

The cohort consisted of 210 patients treated between February 2009 and September 2010 (55% were women), with a mean age of 53.4 ± 13 years and median Hunt and Hess Grade III (interquartile range III–IV). Only 13% (27/210) of patients were exposed to preadmission BB therapy. Compared with these patients, a higher percentage of patients not exposed to preadmission BBs had transcranial Doppler-mean flow velocity ≥ 120 cm/sec (59% vs 22%; p = 0.003). In multivariate analyses, lower Hunt and Hess grade (OR 3.9; p < 0.001) and preadmission BBs (OR 4.5; p = 0.002) were negatively associated with cVSP. In multivariate analysis, LVWMA (OR 2.7; p = 0.002) and low LVEF (OR 1.1; p = 0.05) were independent predictors of in-hospital mortality. Low LVEF (OR 3.9; p = 0.05) independently predicted medically refractory cVSP. The in-hospital mortality rate was higher in patients with LVWMA (47.4% vs 14.8%; p < 0.001).

CONCLUSIONS

The study data suggest that preadmission therapy with BBs is associated with lower incidence of cVSP after aSAH. LV dysfunction was associated with higher medically refractory cVSP and in-hospital mortality. BB therapy may be considered after aSAH as a cardioprotective and cVSP preventive therapy.

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Manasi Ramachandran, Rohini Retarekar, Madhavan L. Raghavan, Benjamin Berkowitz, Benjamin Dickerhoff, Tatiana Correa, Steve Lin, Kevin Johnson, David Hasan, Christopher Ogilvy, Robert Rosenwasser, James Torner, Einar Bogason, Christopher J. Stapleton and Robert E. Harbaugh

OBJECT

The goal of this prospective longitudinal study was to test whether image-derived metrics can differentiate unruptured aneurysms that will become unstable (grow and/or rupture) from those that will remain stable.

METHODS

One hundred seventy-eight patients harboring 198 unruptured cerebral aneurysms for whom clinical observation and follow-up with imaging surveillance was recommended at 4 clinical centers were prospectively recruited into this study. Imaging data (predominantly CT angiography) at initial presentation was recorded. Computational geometry was used to estimate numerous metrics of aneurysm morphology that described the size and shape of the aneurysm. The nonlinear, finite element method was used to estimate uniform pressure-induced peak wall tension. Computational fluid dynamics was used to estimate blood flow metrics. The median follow-up period was 645 days. Longitudinal outcome data on these aneurysm patients—whether their aneurysms grew or ruptured (the unstable group) or remained unchanged (the stable group)—was documented based on follow-up at 4 years after the beginning of recruitment.

RESULTS

Twenty aneurysms (10.1%) grew, but none ruptured. One hundred forty-nine aneurysms (75.3%) remained stable and 29 (14.6%) were lost to follow-up. None of the metrics—including aneurysm size, nonsphericity index, peak wall tension, and low shear stress area—differentiated the stable from unstable groups with statistical significance.

CONCLUSIONS

The findings in this highly selected group do not support the hypothesis that image-derived metrics can predict aneurysm growth in patients who have been selected for observation and imaging surveillance. If aneurysm shape is a significant determinant of invasive versus expectant management, selection bias is a key limitation of this study.

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Nohra Chalouhi, Mario Zanaty, Stavropoula Tjoumakaris, Philip Manasseh, David Hasan, Ketan R. Bulsara, Robert M. Starke, Kevin Lawson, Robert Rosenwasser and Pascal Jabbour

OBJECT

Endovascular interventions have become an essential part of a neurosurgeon’s practice. Whether endovascular procedures have been effectively integrated into residency curricula, however, remains uncertain. The purpose of this study was to assess the preparedness of US neurosurgery graduate trainees for neuroendovascular fellowship.

METHODS

A multidomain, global assessment survey was sent to all directors/faculty of neuroendovascular fellowship programs involved in training of US neurosurgery graduates. Surveyees were asked to assess trainees as they entered fellowship.

RESULTS

The response rate was 78% (25/32). Of respondent program directors, 38% reported that new fellows did not know the history and imaging of the patient and 50% were unable to formulate an appropriate treatment plan. As many as 79% of fellows were unfamiliar with endovascular devices and 75% were unfamiliar with angiographic equipment. Furthermore, 58% of fellows were unable to perform femoral access, 54% were unable to perform femoral closure, 79% were unable to catheterize a major vessel, 86% were unable to perform a 4-vessel angiogram, and 100% were unable to catheterize an aneurysm. Additionally, program directors reported that over 50% of fellows could not recognize neurovascular anatomy and 54% could not recognize/classify vascular abnormalities. There was an overall agreement that fellows demonstrated professionalism and interest in research and had good communication/clinical skills.

CONCLUSIONS

The results of this study suggest potential gaps in the training of neurosurgery residents with regard to endovascular neurosurgery. In an era of minimally invasive therapies, changes in residency curricula may be needed to keep pace with the ever-changing field of neurosurgery.

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Nohra Chalouhi, Mario Zanaty, Alex Whiting, Steven Yang, Stavropoula Tjoumakaris, David Hasan, Robert M. Starke, Shannon Hann, Christine Hammer, David Kung, Robert Rosenwasser and Pascal Jabbour

OBJECT

Flow diverters are increasingly used for treatment of intracranial aneurysms. In most series, the Pipeline Embolization Device (PED) was used for the treatment of large, giant, complex, and fusiform aneurysms. Little is known about the use of the PED in small aneurysms. The purpose of this study was to assess the safety and efficacy of the PED in small aneurysms (≤ 7 mm).

METHODS

A total of 100 consecutive patients were treated with the PED at the authors' institution between May 2011 and September 2013. Data on procedural safety and efficacy were retrospectively collected.

RESULTS

The mean aneurysm size was 5.2 ± 1.5 mm. Seven patients (7%) had sustained a subarachnoid hemorrhage. All except 5 aneurysms (95%) arose from the anterior circulation. The number of PEDs used was 1.2 per aneurysm. Symptomatic procedure-related complications occurred in 3 patients (3%): 1 distal parenchymal hemorrhage that was managed conservatively and 2 ischemic events. At the latest follow-up (mean 6.3 months), 54 (72%) aneurysms were completely occluded (100%), 10 (13%) were nearly completely occluded (≥ 90%), and 11 (15%) were incompletely occluded (< 90%). Six aneurysms (8%) required further treatment. Increasing aneurysm size (OR 3.8, 95% CI 0.99–14; p = 0.05) predicted retreatment. All patients achieved a favorable outcome (modified Rankin Scale Score 0–2) at follow-up.

CONCLUSIONS

In this study, treatment of small aneurysms with the PED was associated with low complication rates and high aneurysm occlusion rates. These findings suggest that the PED is a safe and effective alternative to conventional endovascular techniques for small aneurysms. Randomized trials with long-term follow-up are necessary to determine the optimal treatment that leads to the highest rate of obliteration and the best clinical outcomes.