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An unusual complication of atrial fibrillation ablation: case report

Mentor Petrela, Arben Rroji, Eugen Enesi, Artur Xhumari, and Artid Lame

The authors report a complication of catheter ablation that, to their knowledge, has never been previously reported. A 63-year-old man had undergone successful transvenous catheter thermoablation for atrial fibrillation. The patient remained well until 3 days prior to further admission when he noticed itching in the right frontal area of his scalp. On palpating his scalp, he discovered a metallic body projecting out of it and he proceeded to extract 20 cm of wire from his head. The following day a progressive left hemiplegia developed, and the patient experienced a deteriorating level of consciousness. A CT scan of the brain showed a right frontotemporal intraparenchymal hemorrhage and revealed a metallic structure in the middle of the hematoma. The hematoma was evacuated and a decompressive craniotomy was performed. The guidewire was identified, but it was only possible to extract part of it. It was covered by fibrous tissue, secondary to inflammatory reaction. To the authors’ knowledge, this is the first report of guidewire-induced brain hemorrhage. The guidewire apparently had not been removed and had spontaneously migrated from the heart to the brain and beyond to the scalp where it then exited the patient’s head. The patient had been well before he attempted to pull out the wire. Earlier identification of the iatrogenic complication of a retained guidewire might have prevented the fatal outcome in this case.

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Endovascular therapy of low- and intermediate-grade intracranial lateral dural arteriovenous fistulas: a detailed analysis of primary success rates, complication rates, and long-term follow-up of different technical approaches

Lorenz Ertl, Hartmut Brückmann, Mathias Kunz, Alexander Crispin, and Gunther Fesl

OBJECTIVE

Sinus-preserving (SP) embolization techniques augment endovascular treatment options for intracranial lateral dural arteriovenous fistulas (DAVFs). The authors aimed to perform a retrospective comparison of their primary success rates, complication rates, and long-term follow-up with those of sinus-occluding (SO) treatment variants in the collective of low- and intermediate-grade lateral DAVFs (Cognard Types I–IIb).

METHODS

Clinical symptoms, complication rates, and Cognard grading prior to and after endovascular DAVF treatment using different technical approaches was retrospectively analyzed in 36 patients with lateral DAVF Cognard Types I–IIb. The long-term success rate was determined by a standardized questionnaire.

RESULTS

The SO approaches offered a higher rate of definitive fistula occlusion (93% SO vs 71% SP) but were accompanied by a significantly higher complication rate (33% or 20% SO vs 0% SP). The patients interviewed reported very high satisfaction with their health in long-term follow-up in both groups.

CONCLUSIONS

A higher rate of definitive fistula occlusion in the SO group was attained at the price of a significantly higher complication rate. The SP approaches offered a good primary success rate in combination with a very low complication rate. Despite some limitations of the data (e.g., a small sample size) the authors thus recommend an SP variant as the primary therapeutic option for the endovascular treatment of low- and intermediate-grade DAVFs. The SO approaches should be restricted to cases in which SP treatment does not achieve a downgrading to no worse than Cognard Type IIa.

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Cerebrospinal fluid shunt infection due to Gemella haemolysans

Case report

William B. Lo, Mitul Patel, Guirish A. Solanki, and Anthony Richard Walsh

Gemella haemolysans has long been considered a commensal in the human upper respiratory tract. Commensals are natural inhabitants on or within another organism, deriving benefit without harming or benefiting the host. Opportunistic infection of the CNS by the species is exceedingly rare. In the present case, a 16-year-old boy was admitted with a ventriculoperitoneal shunt infection, which was confirmed to be due to G. haemolysans. Following antibiotic treatment, removal of the old shunt, and delayed insertion of a new shunt, the patient made a full neurological recovery. To the authors' knowledge, this is the eighth case of CNS infection with G. haemolysans. Although prosthesis-related infections have been reported in other systems, this is the first case of CNS infection by the bacterium associated with an implant. Previous reported cases of CNS infection by G. haemolysans are reviewed. Due to the variable Gram staining property of the organism, the difficulty in diagnosing G. haemolysans infection is emphasized.

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Vessel perforation during withdrawal of Trevo ProVue stent retriever during mechanical thrombectomy for acute ischemic stroke

Case report

Lakshmi Leishangthem and Sudhakar R. Satti

The authors report a case of an intracranial extravasation during the withdrawal of a Trevo ProVue stent retriever device in a patient being treated for acute ischemic stroke. An 82-year-old woman developed sudden left hemiparesis and aphasia during an urgent cardiac catheterization procedure for a non–ST elevation myocardial infarction. She had a baseline National Institutes of Health Stroke Scale (NIHSS) score of at least 10 and no improvement with intravenous administration of tissue plasminogen activator (tPA). Cerebral angiography was performed with conscious sedation, confirming an occlusion of the superior division of the right middle cerebral artery (MCA). Using standard technique, a Trevo thrombectomy device was deployed across the clot. Post-thrombectomy control angiography demonstrated complete revascularization of the right MCA. The device was then gently withdrawn without difficulty. Immediately afterward the patient's blood pressure showed a sudden and significant elevation. Immediate posttreatment angiography demonstrated active extravasation from the posterior wall of the communicating segment of the right internal carotid artery. Rapid cessation of bleeding was achieved with intravenous administration of protamine and induced hypotension. Immediate neurological assessment was performed, which showed motor improvement. An immediate postintervention CT scan confirmed a moderate-sized subarachnoid hemorrhage and contrast in the prepontine cistern. The patient was discharged home on postoperative Day 3 with an NIHSS score of zero. At 6-month follow-up in the neurointerventional clinic, her NIHSS and modified Rankin Scale scores were both zero.

Endovascular stent retriever devices are increasingly being used as first-line thrombectomy devices in acute embolic strokes. A unique and previously undescribed complication is vessel perforation during withdrawal of a stent retriever. Conservative treatment options and reversal of anticoagulation should be the first line of treatment for such complications. In the authors' case, performing the procedure without anesthesia was helpful in assessing the patient's neurological status.

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Carotid cutdown for surgical retrieval of a guidewire introducer: an unusual complication after mitral valve repair

Case report

Joshua E. Meyers, Grant C. Sorkin, Hakeem J. Shakir, and Kenneth V. Snyder

With the use of endovascular techniques and indwelling catheters, potential complications can include embolization of fragments or components of various systems. The authors describe the surgical retrieval of a guidewire introducer from the right common carotid artery (CCA). A 64-year-old man was found to have a foreign body within the right CCA on CT angiography after he had presented with a transient ischemic attack. He had undergone a complex mitral valve repair several months before presenting to the authors' facility. That procedure involved a femoral artery cutdown and the insertion of an endovascular aortic balloon for cardiac bypass. As in most endovascular procedures, guidewire introducers were probably used to facilitate the introduction of the guidewire into the system during the procedure. Although rare, iatrogenic embolization of the introducer probably occurred during use of the guidewire. The guidewire introducer was successfully retrieved without complication by using a standard carotid cutdown approach. It is extraordinarily unusual for an extracorporeal part of an implantable system to embolize to the carotid circulation. To the authors' knowledge, this is the only reported case of an embolized guidewire introducer and the use of a carotid exposure to retrieve an intraluminal foreign body. This case demonstrates that a carotid cutdown approach can be used successfully for the retrieval of intraluminal extracranial carotid artery foreign bodies.

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Comparison of non–stent retriever and stent retriever mechanical thrombectomy devices for the endovascular treatment of acute ischemic stroke

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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Balloon-assisted microcatheter navigation for AVM embolization: technical note

George A. C. Mendes, Eduardo Pedrolo Silveira, Suzana Saleme, Christina Iosif, Sanita Ponomarjova, François Caire, and Charbel Mounayer

Recurrent feeders may preclude a successful arterial catheterization of arteriovenous malformations (AVMs). In this paper, the authors report their experience with the use of a compliant balloon to assist the microcatheter navigation in AVMs supplied by feeders with recurrent configuration.

Eight patients with AVMs supplied by recurrent feeders had unsuccessful microcatheter navigation after multiple attempts to catheterize the pedicle. A compliant balloon was inflated in the parent artery immediately after the origin of the feeder. The microcatheter was then advanced over the wire while the balloon provided support for the navigation. Distal access close to the nidus was achieved in all cases. Anatomical cure was documented in 75% cases. There were no arterial perforations or thromboembolic events.

The described technique is a straightforward method for providing support to microcatheter navigation in certain cases of cerebral AVMs supplied by recurrent arterial feeders. This simple yet effective maneuver may enhance outcomes of AVM embolization by eliminating the need for excessive attempts of catheterization.

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Safety and efficacy of the Pipeline embolization device for treatment of intracranial aneurysms: a pooled analysis of 3 large studies

David F. Kallmes, Waleed Brinjikji, Saruhan Cekirge, David Fiorella, Ricardo A. Hanel, Pascal Jabbour, Demetrius Lopes, Pedro Lylyk, Cameron G. McDougall, and Adnan Siddiqui

OBJECTIVE

The authors performed a pooled analysis of 3 studies—IntrePED (International Retrospective Study of the Pipeline Embolization Device), PUFS (Pipeline for Uncoilable or Failed Aneurysms Study), and ASPIRe (Aneurysm Study of Pipeline in an Observational Registry)—in order to assess angiographic outcomes and clinical safety of the Pipeline embolization device (PED).

METHODS

IntrePED was a retrospective study, while PUFS and ASPIRe were prospective studies. For each patient included in these studies, the authors collected baseline demographic data, aneurysm characteristics, and procedural details. The primary outcomes for this combined analysis were clinical outcomes, including neurological morbidity and mortality and major ipsilateral intracranial hemorrhage and ischemic stroke. The secondary outcomes were angiographic occlusion rates, which were available for ASPIRe and PUFS only.

RESULTS

A total of 1092 patients with 1221 aneurysms were included across the 3 studies. The mean aneurysm size was 12.0 ± 7.8 mm and the mean neck size was 6.6 ± 4.8 mm. The major ipsilateral ischemic stroke rate was 3.7% (40/1091). The major ipsilateral intracranial hemorrhage rate was 2.0% (22/1091). The major neurological morbidity rate was 5.7% (62/1091). The neurological mortality rate was 3.3% (36/1091). The combined major morbidity and neurological mortality rate was 7.1% (78/1091). The complete occlusion rates were 75.0% at 180 days (111/148) and 85.5% at 1 year (94/110). The overall aneurysm retreatment rate was 3.0% (33/1091) at a mean follow-up time of 10.2 ± 10.8 months.

CONCLUSIONS

Endovascular treatment of intracranial aneurysms with the PED is safe and effective. Angiographic occlusion rates progressed with follow-up. Rates of stroke, hemorrhage, morbidity and mortality, and retreatment were low, especially given the fact that the aneurysms treated were generally large and wide necked.

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Safety results from the treatment of 109 cerebral aneurysms using the Woven EndoBridge technique: preliminary results in the United Kingdom

Aimee Lawson, Andy Molyneux, Robin Sellar, Saleh Lamin, Allan Thomas, Anil Gholkar, and Tufail Patankar

OBJECTIVE

The Woven Endobridge (WEB) device has been in clinical use for the treatment of brain aneurysms for the past 4 years. Observational studies to assess clinical outcome and related complications have been published. Clear evidence is required to better understand the safety profile of the WEB device. The authors here present a multicenter series that provides a detailed safety analysis focused on patient selection, procedural events, and technical issues of treated patients throughout the United Kingdom (UK).

METHODS

A nationwide password-protected database was set up to collect anonymous information across the UK (14 centers). Complications and clinical outcome were analyzed for the initial 109 patients (112 procedures). An independent root cause analysis classified the complications into groups (procedural, disease, device, ancillary device, and other). The modified Rankin Scale (mRS) was used as a marker of clinical outcome.

RESULTS

Each of the 109 patients had 1 aneurysm suitable for WEB treatment (109 aneurysms). Three patients had 2 procedures, making a total of 112 procedures performed. Eight procedures were abandoned because of access issues; 2 patients went on to have a successful procedure. All 109 patients had a preprocedure and discharge mRS scores recorded. One hundred patients had a recorded mRS score from a > 3-month follow-up.

Deployment of the WEB device was successful in 103 (94.5%) of 109 patients and 104 (92.9%) of 112 procedures. One patient had 2 successful WEB procedures on separate occasions. Patients without a successfully implanted WEB device were included in the analysis. Selection analysis showed that the average patient age was 56.5 years among 34 men and 75 women. The percentage of incidental aneurysms was 58.7%, acute 16.5%, symptomatic 18.3%, and recurrent 6.4%. Further results analysis showed that 40 (36.7%) of 109 patients had recorded adverse events, including those unrelated to the WEB device. Events that could be related to the WEB device numbered 17 (15.6%) among the 109 patients. Two patients with device-related complications were symptomatic. Overall, 11 patients (10.1%) had persistent clinical sequelae. Thromboembolism was the most prevalent event, affecting 15.6% of the patients (17 of 109), and 6.4% of the patients (7 of 109) with a thromboembolism were symptomatic.

Overall mortality before discharge was 0% and at the > 3-month follow-up was 5% (5 of 100 patients). Morbidity was defined as an mRS score increase to > 2. Overall morbidity at discharge was 1.8% (2 of 109) and at the > 3-month follow-up was 6% (6 of 100). No device-related morbidity or mortality was associated with this group.

CONCLUSIONS

The UK data show that the WEB device is safe for clinical use. Thromboembolic complication adds a risk that should be minimized with appropriate anticoagulation and correct sizing of the device. There is scope for further evaluation and standardization of an anticoagulation regimen for the WEB device.

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Endovascular treatment of proximal and distal posterior inferior cerebellar artery aneurysms

Clinical article

Nohra Chalouhi, Pascal Jabbour, Robert M. Starke, Stavropoula I. Tjoumakaris, L. Fernando Gonzalez, Samantha Witte, Robert H. Rosenwasser, and Aaron S. Dumont

Object

Surgical clipping of posterior inferior cerebellar artery (PICA) aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies. The authors assess the feasibility, safety, and efficacy of endovascular therapy in the largest series of proximal and distal PICA aneurysms to date.

Methods

A total of 76 patients, 54 with proximal and 22 with distal PICA aneurysms, underwent endovascular treatment at Jefferson Hospital for Neuroscience between 2001 and 2011.

Results

Endovascular treatment was successful in 52 patients (96.3%) with proximal aneurysms and 19 patients (86.4%) with distal aneurysms. Treatment consisted of selective aneurysm coiling in 60 patients (84.5%) (including 4 with stent assistance and 4 with balloon assistance) and parent vessel trapping in 11 patients (15.5%). Specifically, a deconstructive procedure was necessary in 9.6% of proximal aneurysms (5 of 52) and 31.6% of distal aneurysms (6 of 19). There were 9 overall procedural complications (12.7%), 6 infarcts (8.5%; 4 occurring after deliberate occlusion of the PICA), and 3 intraprocedural ruptures (4.2%). The rate of procedure-related permanent morbidity was 2.8%. Complete aneurysm occlusion was achieved in 63.4% of patients (45 of 71). One patient (1.4%) treated with selective aneurysm coiling suffered a rehemorrhage on postoperative Day 15. The mean angiographic follow-up time was 17.2 months. Recurrence and re-treatment rates were, respectively, 20% and 17.1% for proximal aneurysms compared with 30.8% and 23.1% for distal aneurysms. Favorable outcomes (moderate, mild, or no disability) at follow-up were seen in 93% of patients with unruptured aneurysms and in 78.7% of those with ruptured aneurysms.

Conclusions

Endovascular therapy is a feasible, safe, and effective treatment in patients with proximal and distal PICA aneurysms, providing excellent patient outcomes and adequate protection against rehemorrhage. The long-term incidence of aneurysm recanalization appears to be high, especially in distal aneurysms, and requires careful angiographic follow-up.