Elad I. Levy, Adnan H. Siddiqui and L. Nelson Hopkins
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.
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.
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.
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.
Report of two cases
Robert D. Ecker, Ramachandra P. Tummala, Elad I. Levy and L. Nelson Hopkins
✓Both carotid endarterectomy and carotid artery stent placement with filter embolic protection present a higher risk for patients with internal carotid artery (ICA) lesions containing intraluminal thrombus. Despite the risk associated with intervention, patients with symptomatic intraluminal thrombus who were enrolled in the North American Symptomatic Endarterectomy Trial did better with surgical than medical treatment. We describe the novel use of an endovascular “internal cross-clamping” technique in two patients with symptomatic intraluminal thrombus in the ICA. A 57-year-old woman presented with a history of multiple episodes of left upper-extremity numbness, mild dysarthria, and agraphia occurring over the previous 24 hours. Cranial magnetic resonance imaging revealed a scattered watershed infarction of the right hemisphere and a critical stenosis of the right ICA. An 81-year-old man awoke with hemiplegia and inability to follow commands after undergoing a complicated carotid endarterectomy. Computed tomographic perfusion imaging demonstrated an increased time to peak in the left middle cerebral territory, and emergent angiography demonstrated both intimal flaps and thrombus in the endarterectomy bed. The lesions in both patients were treated with endovascular stent placement using both proximal and distal flow occlusion—a functional “internal cross-clamping”—for embolic protection. To our knowledge, this is the first report of internal trapping and stent placement for symptomatic carotid stenosis containing intraluminal thrombus. This treatment strategy should be added to the armamentarium of endovascular surgeons in selected patients with symptomatic carotid intraluminal thrombus.
Sharon Webb, Parham Yashar, Peter Kan, Adnan H. Siddiqui, L. Nelson Hopkins and Elad I. Levy
The treatment of acute intracranial vertebrobasilar artery occlusion (VBO) has been described but often with poor results. The authors of this study set out to evaluate their institution's outcomes following multimodal treatment of VBO.
They retrospectively reviewed their endovascular database for all patients treated for acute intracranial VBO between December 2004 and June 2010. Twenty-four patients were identified. Two patients were excluded from evaluation—one because of incomplete medical records and one because the etiology was basilar stenosis and not stroke. Occlusion location, hypercoagulable causes, time to endovascular treatment, time to revascularization, comorbidities, devices used, procedural anticoagulation, and outcomes were analyzed.
Among the 22 eligible study patients, the mean National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15.3. The mean time from presentation to initiation of the endovascular procedure was 4.77 hours. The mean time for recanalization from the start of angiography was 1.63 hours. In 16 patients (73%), revascularization was successful (Thrombolysis in Myocardial Infarction [TIMI] score of 2 or 3). Thirteen (59%) of the 22 patients were discharged to home or a rehabilitation facility. One patient was transferred to a chronic care facility. The overall survival rate was 64%. The average NIHSS score for the 14 surviving patients at discharge was 3.9. At the follow-up (average 14.5 months, range 1–58 months), 10 patients (71%) had achieved good outcomes (modified Rankin Scale [mRS] score ≤ 2) and 4 (29%) had poor outcomes (mRS Score 3–6).
Published case series have historically shown poor outcomes and high mortality rates in association with the treatment of acute VBO, prompting surgeons to be less aggressive in the treatment of this disease than they might be otherwise. Data in this series show that the revascularization of posterior circulation occlusions is feasible and that good outcomes and lower mortality rates with newer endovascular technologies are possible, and thus more prompt and aggressive treatment of this disease may be warranted.