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Clemens M. Schirmer, Daniel A. Hoit and Adel M. Malek


Distal protection devices (DPDs) have decreased the risk of embolic stroke among patients with carotid artery (CA) disease undergoing CA stent placement. The FilterWire EX is a first-generation fixed-basket DPD with a filter rigidly attached to a guidewire. Second-generation mobile-basket DPDs (RX Accunet or SpiderFX) allow movement of the filter relative to the guidewire and can thus reduce the potential for vessel irritation, vasospasm, or intimal injury during CA stent placement.


Stent angioplasty was attempted in 40 CAs (37 patients) using the fixed-basket FilterWire DPD, a second-generation mobile-basket DPD, or no protection in 12, 6, and 22 arteries, respectively. Clinical presentation, angiographic details relating to the incidence of vasospasm or dissection, and clinical outcome data were recorded and analyzed.


Vasospasm was associated with use of the fixed-basket FilterWire device (8 [67%] of 12 cases) compared with the bare unfiltered guidewire group (3 [14%] of 22) and the second-generation mobile-basket DPD group (1 [17%] of 6, p < 0.004). Secondary angioplasty was also associated with intraprocedural vasospasm. In a multivariate analysis, FilterWire use was an independent risk factor for vasospasm (p < 0.0003).


A high incidence of vasospasm was observed following CA stent placement procedures in which the fixed-basket FilterWire EX DPD was used but not in unprotected CA stent placement or procedures in which a second-generation mobile-basket DPD was used. Although this phenomenon was self-limited in all instances, vasospasm should be considered a risk of these devices and may predispose to more serious vascular injury. Coronary artery stent placement should be performed with a second-generation mobile-basket DPD to minimize the risks of embolic complications and iatrogenic vascular injury.

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Jeffrey E. Arle, Diana Apetauerova, Janet Zani, D. Vedran Deletis, Dana L. Penney, Daniel Hoit, Christine Gould and Jay L. Shils


Since the initial 1991 report by Tsubokawa et al., stimulation of the M1 region of cortex has been used to treat chronic pain conditions and a variety of movement disorders.


A Medline search of the literature published between 1991 and the beginning of 2007 revealed 459 cases in which motor cortex stimulation (MCS) was used. Of these, 72 were related to a movement disorder. More recently, up to 16 patients specifically with Parkinson disease were treated with MCS, and a variety of results were reported. In this report the authors describe 4 patients who were treated with extradural MCS.


Although there were benefits seen within the first 6 months in Unified Parkinson's Disease Rating Scale Part III scores (decreased by 60%), tremor was only modestly managed with MCS in this group, and most benefits seen initially were lost by the end of 12 months.


Although there have been some positive findings using MCS for Parkinson disease, a larger study may be needed to better determine if it should be pursued as an alternative surgical treatment to DBS.

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Benjamin L. Brown, Demetrius Lopes, David A. Miller, Rabih G. Tawk, Leonardo B. C. Brasiliense, Andrew Ringer, Eric Sauvageau, Ciarán J. Powers, Adam Arthur, Daniel Hoit, Kenneth Snyder, Adnan Siddiqui, Elad Levy, L. Nelson Hopkins, Hugo Cuellar, Rafael Rodriguez-Mercado, Erol Veznedaroglu, Mandy Binning, J Mocco, Pedro Aguilar-Salinas, Alan Boulos, Junichi Yamamoto and Ricardo A. Hanel


The authors sought to determine whether flow diversion with the Pipeline Embolization Device (PED) can approximate microsurgical decompression in restoring function after cranial neuropathy following carotid artery aneurysms.


This multiinstitutional retrospective study involved 45 patients treated with PED across the United States. All patients included presented between November 2009 and October 2013 with cranial neuropathy (cranial nerves [CNs] II, III, IV, and VI) due to intracranial aneurysm. Outcome analysis included clinical and procedural variables at the time of treatment as well as at the latest clinical and radiographic follow-up.


Twenty-six aneurysms (57.8%) were located in the cavernous segment, while 6 (13.3%) were in the clinoid segment, and 13 (28.9%) were in the ophthalmic segment of the internal carotid artery. The average aneurysm size was 18.6 mm (range 4–35 mm), and the average number of flow diverters placed per patient was 1.2. Thirty-eight patients had available information regarding duration of cranial neuropathy prior to treatment. Eleven patients (28.9%) were treated within 1 month of symptom onset, while 27 (71.1%) were treated after 1 month of symptoms. The overall rate of cranial neuropathy improvement for all patients was 66.7%. The CN deficits resolved in 19 patients (42.2%), improved in 11 (24.4%), were unchanged in 14 (31.1%), and worsened in 1 (2.2%). Overtime, the rate of cranial neuropathy improvement was 33.3% (15/45), 68.8% (22/32), and 81.0% (17/21) at less than 6, 6, and 12 months, respectively. At last follow-up, 60% of patients in the isolated CN II group had improvement, while in the CN III, IV, or VI group, 85.7% had improved. Moreover, 100% (11/11) of patients experienced improvement if they were treated within 1 month of symptom onset, whereas 44.4% (12/27) experienced improvement if they treated after 1 month of symptom onset; 70.4% (19/27) of those with partial deficits improved compared with 30% (3/10) of those with complete deficits.


Cranial neuropathy caused by cerebral aneurysm responds similarly when the aneurysm is treated with the PED compared with open surgery and coil embolization. Lower morbidity and higher occlusion rates obtained with the PED may suggest it as treatment of choice for some of these lesions. Time to treatment is an important consideration regardless of treatment modality.