H yperglycemia at the time of ischemic stroke presentation has been shown to be associated with poor outcomes 5 , 23 , 30 and reduced salvage of ischemic penumbra from infarction, and it corresponds with a larger final infarct size (as measured by MR imaging). 2 , 8 , 20 , 22 Patients undergoing endovascular therapy for AIS represent a highly selected cohort due to the following factors: 1) they are treated up to 8 hours after the onset of stroke symptoms (as supported by the MERCI, 11 , 25 Multi MERCI, 24 and Penumbra 21 trials); 2) they have higher
Sabareesh K. Natarajan, Paresh Dandona, Yuval Karmon, Albert J. Yoo, Junaid S. Kalia, Qing Hao, Daniel P. Hsu, L. Nelson Hopkins, David J. Fiorella, Bernard R. Bendok, Thanh N. Nguyen, Marilyn M. Rymer, Ashish Nanda, David S. Liebeskind, Osama O. Zaidat, Raul G. Nogueira, Adnan H. Siddiqui, and Elad I. Levy
Shuichi Suzuki, Reza Jahan, Gary R. Duckwiler, John Frazee, Neil Martin, and Fernando Viñuela
facility or a delay before the patient could be medically stabilized prior to the procedure. The indications for endovascular therapy included anticipated surgical difficulty in six patients (5.4%), failed aneurysm clip placement in 15 patients (13.5%), and poor neurological grade or medical condition in 90 patients (81.1%). Technical Points of Endovascular Coil Embolization All endovascular coil embolization procedures were performed by two interventional neuroradiologists in a dedicated neurointerventional angiography suite. All patients were in a state of
Christina M. Sayama, James K. Liu, and William T. Couldwell
✓Cerebral vasospasm remains a major source of morbidity and death in patients with aneurysmal subarachnoid hemorrhage (SAH). When vasospasm becomes refractory to maximal medical management consisting of induced hypertension and hypervolemia and administration of calcium channel antagonists, endovascular therapies should be considered. The primary goal of endovascular treatment is to increase cerebral blood flow to prevent cerebral infarction. Two of the more frequently studied endovascular treatments are transluminal balloon angioplasty and intraarterial papaverine infusion. These two have been used either alone or in combination for the treatment of vasospasm. Other pharmacological vasodilating agents currently being investigated are intraarterial nimodipine, nicardipine, verapamil, and milrinone. Newer intraarterial agents, such as fasudil and colforsin daropate, have also been investigated. In this article the authors review the current options in terms of endovascular therapies for treatment of cerebral vasospasm. The mechanism of action, technique of administration, clinical effect and outcomes, and complications of each modality are discussed.
Yassine Kanaan, David Kaneshiro, Kenneth Fraser, David Wang, and Giuseppe Lanzino
The endovascular treatment of intracranial aneurysms has recently become an established therapeutic option. The foundation of this treatment modality was laid by the work done in ground-breaking cases, combined with technological advances since the first half of the 19th century. In this historical overview the authors describe the steps taken by the early pioneers and the results of their work, which was often done under challenging circumstances. The work of these predecessors established the stepping-stones for constant development and refinement for those who have come after them, eventually evolving into the procedures used today. Endovascular treatment of intracranial aneurysms is only possible because of the work of these innovators.
Siamak Asgari, Arnd Doerfler, Isabel Wanke, Beate Schoch, Michael Forsting, and Dietmar Stolke
T he primary aims in aneurysm therapy are to prevent rebleeding and to achieve complete occlusion of the aneurysm with preservation of the parent vessel. After endovascular therapy, the degree of occlusion is estimated from the final angiography study. After clipping, however, the routine use of postoperative angiography for cerebral aneurysms is a matter of ongoing debate. In a large microsurgical treatment series, postoperative angiography demonstrated residual aneurysms in 1.6 to 14% of cases. 3, 20, 27, 31 The incidence of rerupture for the postoperative
Thanh N. Nguyen, Jean Raymond, François Guilbert, Daniel Roy, Maxime D. Bérubé, Mostafa Mahmoud, and Alain Weill
P rocedure-related rupture, one of the most feared complications of endovascular therapy for ruptured aneurysms, is associated with high rates of neurological disability (5–63%) 2 , 7 and mortality (20–63%). 4 , 12 , 13 , 16 In a large meta-analysis, ruptured aneurysm was confirmed as a risk factor for procedure-related rupture. 2 Small size has also been reported as a risk factor, 14 , 18 but this was recently challenged. 15 Confirmation of size as a risk factor for procedure-related rupture is important for better estimates of patient risk
Rocco A. Armonda, Jeffrey E. Thomas, and Robert H. Rosenwasser
Endovascular surgical technology is in the early stages of evolution. A critical phase of this development has been microcatheter technology, which has permitted sufficiently precise intravascular navigation to safely engage the lumen of the aneurysm itself. Digital subtraction angiography, rapid filming techniques and image acquisition, and simultaneous multiplanar imaging capability are indispensable tools that are constantly being refined in the setting of ever-improving computer technology. The marriage of these different technologies has allowed effective endovascular treatment of difficult-to-access aneurysms in medically compromised patients for whom open microsurgery has inherently higher risks.
Haitham Dababneh, Waldo R. Guerrero, Anna Khanna, Brian L. Hoh, and J Mocco
Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant internal carotid artery (ICA) occlusion, and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. The authors report their experience with acute ischemic stroke patients who suffered tandem ICA/MCA (TIM) occlusions and underwent intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial MCA mechanical thrombectomy.
In a retrospective analysis of their stroke database (2008–2011), the authors identified 2 patients with TIM occlusion treated with intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy. They examined early neurological improvement defined by a greater than 10-point reduction of National Institutes of Health Stroke Scale (NIHSS) score and an improved modified Rankin Scale (mRS) score at 60 days. Successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2 or 3 was also evaluated.
In both patients a TICI score of 2b or 3 was achieved, signifying successful recanalization. In addition, both patients had a reduction in the NIHSS score by greater than 10 points and an mRS score of 0 at 60 days.
Tandem occlusions of the cervical ICA and MCA may be successfully treated using the multimodality approach of intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy.
Stanley L. Barnwell, Van V. Halbach, Christopher F. Dowd, Randall T. Higashida, Grant B. Hieshima, and Charles B. Wilson
✓ Dural arteriovenous (AV) fistulas are thought to be acquired lesions that form in an area of thrombosis within a sinus. If the sinus remains completely thrombosed, venous drainage from these lesions occurs through cortical veins, or, if the sinus is open, venous drainage is usually into the involved sinus. Among 105 patients with dural A V fistulas evaluated over the the past 5 years, seven had a unique type of dural AV fistula in the superior sagittal, transverse, or straight sinus in which only cortical venous drainage occurred despite a patent involved sinus; the fistula was located within the wall of a patent dural sinus, but outflow was not into the involved sinus. This variant of dural AV fistulas puts the patient at serious risk for hemorrhage or neurological dysfunction caused by venous hypertension. Three patients presented with hemorrhage, one with progressive neurological dysfunction, one with seizures, and two with bruit and headaches. A combination of surgical and endovascular techniques was used to close the fistula while preserving flow through the sinus.
John B. Weigele, John C. Chaloupka, and Walter S. Lesley
tumor. The initial findings were actually due to a galenic DAVF that caused reversible interstitial edema at the brainstem. The neuroimaging evaluation and endovascular therapy are discussed. Case Report This 53-year-old man presented with a several-month history of dizziness, double vision, perioral numbness, and personality changes. Examination The patient displayed left fifth, bilateral sixth, and right seventh cranial neuropathies, decreased sensation to pinprick on the right side, and dysdiadochokinesia on the left side. Magnetic resonance images of