Elad I. Levy, Adnan H. Siddiqui and L. Nelson Hopkins
Robert D. Ecker, Tsz Lau, Elad I. Levy and L. Nelson Hopkins
There is no known standard 30-day morbidity and mortality rate for high-risk patients undergoing carotid artery (CA) angioplasty and stent (CAS) placement. The high-risk registries and the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy, Carotid Revascularization using Endarterectomy or Stenting Systems, and European Long-term Carotid Artery Stenting trials report different rates of morbidity and mortality, and each high-risk cohort has a different risk profile. The applicability of carotid endarterectomy (CEA) results from North American Symptomatic Carotid Endarterectomy Trial/Asymptomatic Carotid Atherosclerosis Study (NASCET/ACAS) remains uncertain, as most clinical CAS placement series reported to date typically included patients who would not have qualified for those studies. At the University at Buffalo, the same neurosurgeons perform triage in patients with CA disease and perform both CEA and CAS insertion. The authors review morbidity and mortality rates in this practice model.
Diagnosis-related group codes were used to search the authors’ practice database for patients who had undergone a completed CA intervention solely for the indication of atherosclerotic disease. One hundred twenty patients (129 vessels) treated with CAS surgery and 95 patients (100 vessels) treated with CEA met these criteria. In the CAS placement group, 78% of the patients would not have met NASCET/ACAS inclusion criteria. Demographic and clinical data for both groups were recorded on a spreadsheet for analysis.
At 30 days, one patient in the CEA group and two in the CAS group had died. Stroke occurred in one patient in the CAS group and none in the CEA group. Myocardial infarction (MI) occurred in one patient who underwent CAS surgery compared with three undergoing CEA. Composite incidence of stroke/death/MI was 3.3% in the CAS group and 3.2% in the CEA group.
In a practice in which surgeons perform both CEA and CAS surgery, the event rates for the CAS surgery equivalent to NASCET and ACAS rates for CEA can be achieved, even in high-risk NASCET/ACAS-ineligible patients in 78% of the CAS cases.
Giuseppe Lanzino and Pietro Ivo D'Urso
Elad I. Levy, John D. Heiss, Michael S. Kent, Charles J. Riedel and Edward H. Oldfield
U The pathophysiology of syrinx development is controversial. The authors report on a patient with progressive cervical myelopathy and a Chiari I malformation in whom spinal cord swelling preceded, by a few months, the development of a syrinx in the same location. The patient underwent a craniocervical decompressive procedure and duraplasty, and complete resolution of cord swelling and syringomyelia was achieved. This report is consistent with the theory that patients with Chiari I malformation have increased transmural flow of cerebrospinal fluid, which causes spinal cord swelling that later coalesces into a syrinx. The pathophysiology of syrinx development from spinal cord edema and the success of surgical decompressive treatments that do not invade the central nervous system support the prompt treatment of patients with spinal cord edema who are at risk for the development of a syrinx.
Stanley H. Kim, Adnan I. Qureshi, Elad I. Levy, Ricardo A. Hanel, Amir M. Siddiqui and L. Nelson Hopkins
✓ The authors report a case of emergency carotid artery (CA) stent placement for a symptomatic acute CA occlusion following carotid endarterectomy (CEA). This 43-year-old man underwent a right-sided CEA for an asymptomatic 80% CA stenosis detected using duplex ultrasound testing. The patient experienced hypotension and possibly a myocardial infarction intraoperatively and a left hemiplegia immediately postoperatively. He was referred to the authors' institution for consideration of emergency coronary intervention and evaluation of stroke. A computerized tomography scan of the head demonstrated subtle early ischemic changes in the right posterior parietal region. Cerebral angiography revealed occlusion of the right common CA (CCA) at the CA bifurcation. Two coronary stents (Magic Wall; Boston Scientific Scimed, Maple Grove, MN) were placed in tandem in the right CCA and internal CA (ICA), overlapping at the proximal cervical ICA. Complete recanalization of the CA was achieved, and the patient made a clinically significant recovery. Diagnostic angiography can provide important information about CA and intracranial circulation that will aid in the evaluation of postoperative stroke after CEA. Stent placement should be considered as an alternative method of treatment for acute CA occlusion or dissection following CEA.
Kunal Vakharia, Stephan A. Munich, Michael K. Tso, Muhammad Waqas and Elad I. Levy
Stent-assisted coiling offers a potential solution for coil embolization of broad-based aneurysms. Challenges associated with navigating a microcatheter beyond these aneurysms sometimes require looping the microcatheter within the aneurysm dome. Reducing microcatheter loops within domes can be difficult, and anchor techniques have been described, including balloon anchor, stent-retriever anchor, and stent anchor techniques. The authors present a patient requiring stent-assisted coiling of an anterior communicating artery aneurysm in whom a stent anchor technique was used to reduce a microcatheter loop within an aneurysm dome before coil embolization. Postembolization angiographic runs showed complete coil occlusion of the aneurysm with approximately 35% packing density.
The video can be found here: https://youtu.be/zHR1ZOArUro.
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.
Elizabeth C. Tyler-Kabara, Amin B. Kassam, Michael H. Horowitz, Louise Urgo, Constantinos Hadjipanayis, Elad I. Levy and Yue-Fang Chang
Object. Microvascular decompression (MVD) has become one of the primary treatments for typical trigeminal neuralgia (TN). Not all patients with facial pain, however, suffer from the typical form of this disease; many patients who present for surgical intervention actually have atypical TN. The authors compare the results of MVD performed for typical and atypical TN at their institution.
Methods. The results of 2675 MVDs in 2264 patients were reviewed using information obtained from the department database. The authors examined immediate postoperative relief in 2003 patients with typical and 672 with atypical TN, and long-term follow-up results in patients for whom more than 5 years of follow-up data were available (969 with typical and 219 with atypical TN). Outcomes were divided into three categories: excellent, pain relief without medication; good, mild or intermittent pain controlled with low-dose medication; and poor, no or poor pain relief with large amounts of medication. The results for typical and atypical TN were compared and patient history and pain characteristics were evaluated for possible predictive factors.
Conclusions. In this study, MVD for typical TN resulted in complete postoperative pain relief in 80% of patients, compared with 47% with complete relief in those with atypical TN. Significant pain relief was achieved after 97% of MVDs in patients with typical TN and after 87% of these procedures for atypical TN. When patients were followed for more than 5 years, the long-term pain relief after MVD for those with typical TN was excellent in 73% and good in an additional 7%, for an overall significant pain relief in 80% of patients. In contrast, following MVD for atypical TN, the long-term results were excellent in only 35% of cases and good in an additional 16%, for overall significant pain relief in only 51%. Memorable onset and trigger points were predictive of better postoperative pain relief in both atypical and typical TN. Preoperative sensory loss was a negative predictor for good long-term results following MVD for atypical TN.
Peter T. Kan, Kenneth V. Snyder, Parham Yashar, Adnan H. Siddiqui, L. Nelson Hopkins and Elad I. Levy
Computed tomography perfusion scanning generates physiological flow parameters of the brain parenchyma, allowing differentiation of ischemic penumbra and core infarct. Perfusion maps, along with the National Institutes of Health Stroke Scale score, are used as the bases for endovascular stroke intervention at the authors' institute, regardless of the time interval from stroke onset. With case examples, the authors illustrate their perfusion-based imaging guidelines in patient selection for endovascular treatment in the setting of acute stroke.