Abstract TP235: No Off-Hours or Weekend Effect on Door-In to Door-Out Time in Patients Transferred for Thrombectomy

Introduction: Time-sensitive therapies can be delayed during weekends or off-hours. Regional systems of care require interfacility transfers from Primary Stroke Centers (PSC) to Comprehensive Stroke Centers (CSC). Door-in to door-out (DIDO) time, an emerging performance measure, is a modifiable factor in time to thrombectomy. Off-hours presentation has been associated with longer Door-To-Needle (DTN) time, however its effect on DIDO time is unknown.

Hypothesis: Presentation during off-hours (before 8 AM, after 5 PM or on weekends) prolongs DIDO time.

Methods: Retrospective review of transfers for CT perfusion or thrombectomy from 4 PSC to a CSC between 1/2017 and 6/2019. We used Mann-Whitney for hypothesis testing and Spearman’s correlation.

Results: Sixty-seven persons were included, of which 36 were male, 31 received IV tPA, 40 presented during off-hours. Median (upper and lower quartile) for age, NIHSS, DTN and DIDO were 74 (61-83) years, 17 (12-23) points, 37 (31-54) and 98 (77-127) minutes, respectively. Off-hours presentation did not prolong DIDO time (p=0.32, image) nor affect any interval in the sequence door-in, non-contrast CT (nCT), IV tPA, CT Angiogram (CTA) initiation, CTA interpretation, door-out; or door-in at PSC to groin puncture (DTGP) time. Transport from PSC to CSC was slower off-hours (p=0.04). On post-hoc analyses, DIDO correlated with door-in to nCT interpretation time (r s =0.27, p=0.02), nCT interpretation to consulting neurointerventionalist (r s =0.59, p<0.01) and their acceptance of a transfer (r s =0.37, p=0.01); door-in to CTA initiation (r s =0.77, p<0.01), CTA initiation to interpretation (r s =0.61, p<0.01), and DTGP time (r s =0.85, p<0.01).

Conclusions: Off-hours presentation is not associated with prolonged DIDO time in patients transferred for possible thrombectomy. Time to calling neurointerventionalist and initiation and interpretation of CTA contributes to DIDO, and may be targets for improvement to expedite transfers.

Consecutive Endovascular Treatment of 20 Ruptured Very Small (<3 mm) Anterior Communicating Artery Aneurysms

BACKGROUND

Small aneurysms located at the anterior communicating artery carry significant procedural challenges due to a complex anatomy. Recent advances in endovascular technologies have expanded the use of coil embolization for small aneurysm treatment. However, limited reports describe their safety and efficacy profiles in very small anterior communicating artery aneurysms.

OBJECTIVE

We sought to review and report the immediate and long-term clinical as well as radiographic outcomes of consecutive patients with ruptured very small anterior communicating artery aneurysms treated with current endovascular coil embolization techniques.

METHODS

A prospectively maintained single-institution neuroendovascular database was accessed to identify consecutive cases of very small (<3 mm) ruptured anterior communicating artery aneurysms treated endovascularly between 2006 and 2013.

RESULTS

A total of 20 patients with ruptured very small (<3 mm) anterior communicating artery aneurysms were consecutively treated with coil embolization. The average maximum diameter was 2.66 ± 0.41 mm. Complete aneurysm occlusion was achieved for 17 (85%) aneurysms and near-complete aneurysm occlusion for 3 (15%) aneurysms. Intraoperative perforation was seen in 2 (10%) patients without any clinical worsening or need for an external ventricular drain. A thromboembolic event occurred in 1 (5 %) patient without clinical worsening or radiologic infarct. Median clinical follow-up was 12 (±14.1) months and median imaging follow-up was 12 (±18.4) months.

CONCLUSION

This report describes the largest series of consecutive endovascular treatments of ruptured very small anterior communicating artery aneurysms. These findings suggest that coil embolization of very small aneurysms in this location can be performed with acceptable rates of complications and recanalization.

Predictors and Outcomes Associated with Rescue Therapy in SWIFT

INTRODUCTION

In the Solitaire With the Intention For Thrombectomy (SWIFT) trial, rescue therapy was used when the Solitaire or Merci device was unable to restore vessel patency. Markers for nonrecanalization in acute stroke have been reported for intravenous tissue plasminogen activator; however, similar predictors are not known for endovascular therapy. We sought to identify predictors and outcomes associated with rescue therapy in the SWIFT trial.

METHODS

Rescue therapy included the use of an alternative device, agent, or maneuver following failure to recanalize with three retrieval attempts using the initial device. Clinical, angiographic, and demographic data was reviewed.

RESULTS

Among a total of 144 patients enrolled, 43 (29.9%) required rescue therapy. We used the same baseline demographics for patients with and without rescue therapy. Rescue therapy was used in a higher percentage of patients randomized to the Merci group compared with the Solitaire group (43 vs. 21%, p = 0.009). Patients with rescue therapy experienced a longer recanalization time (p < 0.001), a lower percentage of successful recanalization (p < 0.001), and a lower percentage of good outcome (p = 0.009). In multivariate analysis, patients randomized to the Merci group (OR 3.99, 95% CI 1.58, 10.10) and age >80 years (OR 3.51, 95% CI 1.06, 11.64) were predictors of rescue therapy.

CONCLUSIONS

Merci treatment group and age were predictors of rescue therapy, while a trend toward an increased need of rescue therapy was observed with hypertension and proximal clot location. Rescue therapy was associated with fewer good outcomes. These findings may reflect targets for improvement in endovascular therapy.

Angiographic lumen changes associated with oversized intracranial stent implantation for aneurysm treatment

BACKGROUND

The effect of oversized intracranial stent implantation, and potential excessive neointimal hyperplasia from the chronic outward radial force, has not been reported. We sought to compare the angiographic narrowing associated with implantation of oversized stents.

METHODS

We reviewed an aneurysm database and identified patients treated with stent-assisted embolization involving a vessel size transition. Demographics and lesion characteristics were extracted. The relationship between lumen diameter and stent oversizing was compared.

RESULTS

Twenty vessels were identified in 18 patients, providing 80 paired data points. Mean follow-up time was 8 months (SD 6). The average oversizing in the smaller diameter parent vessel landing-zone was 1.75 mm. Mean change in lumen size from pre-stent implantation was not significantly different for any of the four sites. There was a significant difference in change of lumen size at the stent tines when compared with the respective mid-stent segment for both the proximal (P = 0.02) and distal (P = 0.0004) landing zones.

CONCLUSIONS

A small significant lumen loss occurs at stent tines when compared to midstent struts. However, there is no overall significant stenosis from highly oversized stents. Persistent luminal gain from the oversized stent radial force likely predominates over any neointimal hyperplasia.

The diagnosis and management of brain arteriovenous malformations

Although uncommon in the general population, cerebral arteriovenous malformations (AVMs) can pose a significant health risk if a rupture occurs. Advances in noninvasive imaging have led to an increase in the identification of unruptured AVMs, presenting new challenges in management, given their poorly understood natural history. Over the past decade, there have been significant developments in the management and treatment of intracranial AVMs. This article discusses the pathophysiology, natural history, clinical presentations, and current treatment options, including multimodal approaches, for these vascular malformations.

Venous sinus pulsatility and the potential role of dural incompetence in idiopathic intracranial hypertension

BACKGROUND

Idiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing; however, a complete understanding of the hydrodynamic dysequilibrium is lacking.

OBJECTIVE

To review and characterize catheter manometry findings including pulsatility changes within the venous sinuses in IIH.

METHODS

Cases of venous sinus stent implantation for IIH were retrospectively reviewed.

RESULTS

Three cases of venous sinus stent implantation for treatment of IIH are reported. All cases demonstrated severe narrowing (>70%) within the transverse sinus and a high pressure gradient across the lesion (>30 mm Hg). Stent implantation resulted in pulsatility attenuation, correction of pressure gradient, and improvement of flow.

CONCLUSION

We report the finding of high venous sinus pulsatility attenuation after stent implantation for dural sinus narrowing and propose the hypothesis that this finding is a marker of advanced dural sinus incompetence. This characteristic may be useful in identifying patients who would benefit from endovascular stent remodeling.

Abstract TP4: How Long is Too Long: The Effect of Thrombectomy Procedure Duration on Outcome in Revascularized SWIFT Trial Patients

Introduction: Thrombectomy procedure start time to recanalization has been may be an important predictor of clinical outcome following endovascular therapy of acute ischemic stroke (AIS) patients. In this study, we sought to assess the impact of groin puncture time to revascularization (procedure duration) on outcomes in the multicenter, randomized Solitaire FR with the Intention for Thrombectomy (SWIFT) trial.

Methods: AIS patients enrolled in the SWIFT trial who achieved the primary endpoint of successful recanalization without hemorrhage (SR-sICH) were included. The procedure duration (PD) was defined as time from groin puncture to revascularization. The PD was the main predictor variable. The main outcome variables were the 90 days modified Rankin’s Scale (mRS)≤2; good neurologic outcome (Rankin’s Scale (mRS)≤2 or NIHSS Improvement of≥0), and mortality. Patient demographic, clinical, and angiographic data was reviewed and p-values were calculated using Wilcoxon, linear regression, Cochran Mantel-Haenzsel, or Fischer exact tests.

Results: A total of 63 patients achieved SR-sICH and were enrolled in this analysis. A trend of lower mortality rate was noted in those with shorter PD (31(20)) vs. 36(16) minutes,p=0.2). Patients with mRS≤2 had a PD mean time of 36(21) vs. 30(17) minutes,p=0.3. No statistical effect was noted when comparing mortality and mRS within the quartiles of PD time (p=0.39 and p=0.41, respectively). No statistical difference in mRS, good neurological outcome, and mortality when PD dichotomizing to≤1 hour (n=59) vs. >1 hour (n=4). A multivariate model for predicting mRS at 90 days which included PD, age, initial NIHSS, atrial fibrillation, gender, initial systolic and diastolic blood pressure, showed no statistical significance of PD (p=0.8).

Conclusions: Thrombectomy procedure duration, defined as time from groin puncture to revascularization, did not show a relationship with mRS or good neurological outcome in revascularized patients of the SWIFT trial. A trend toward lower mortality was noted in patients who had a shorter PD. Additional larger sample size prospective trials are needed to clarify the role of PD on clinical outcome.

Abstract WMP3: Predictors And Outcomes Associated With Rescue Therapy In SWIFT

Introduction: In the Solitaire With the Intention For Thrombectomy (SWIFT) trial, rescue therapy was used when the Solitaire or Merci device was unable to restore vessel patency. Markers for non-recanalization in acute stroke have been reported for IV tPA, however similar predictors are not known for endovascular therapy. We sought to identify predictors and outcomes associated with rescue therapy in the SWIFT trial.

Methods: Rescue therapy was defined per SWIFT study protocol, and included the use of an alternative device, agent, or maneuver following failure to recanalize with 3 retrieval attempts using the initial device. Clinical, angiographic, and demographic data was reviewed. Statistical analysis was performed using t-test or Wilcoxon methods and multivariate logistic regression analyses.

Results: Among a total of 144 patients enrolled (31 roll-in phase Solitaire patients, and 113 randomized patients, 58 Solitaire, 55 Merci), 43 (29.9%) required rescue therapy. Baseline demographics for patients with and without rescue therapy were no different. Rescue therapy was used in a higher percentage of patients randomized to Merci than Solitaire (43% vs 21%, p = 0.009). Patients with rescue therapy experienced longer time to recanalization (p < 0.001), a lower percentage of successful recanalization (p < 0.001), and a lower percentage of good outcome (p = 0.009). In multivariate analysis, predictors of rescue therapy were those patients randomized to the Merci group (OR 3.99, 95% CI 1.58, 10.10) and patients over age 80 years (OR 3.51, 95% CI 1.06, 11.64). Non-significant trends toward an increased need for rescue therapy were observed in patients with hypertension (p = 0.09), and occlusions of the carotid terminus and M1 MCA compared with other locations (p = 0.10). No association was observed with rescue therapy and afib (p = 0.47) or IV tPA failure (p = 0.49), and rescue therapy was not associated with symptomatic ICH (p = 0.43).

Conclusions: Predictors of rescue therapy included Merci treatment group and age, while trend toward an increased need of rescue therapy was observed with hypertension and proximal clot location. Rescue therapy was associated with fewer good outcomes. These findings may reflect targets for improvement in endovascular therapy.

Abstract TP24: Time from Symptoms Onset to Revascularization: Impact on Outcomes in Revascularized Swift Trial Patients

Introduction: Time from symptoms onset to revascularization (TOR) has been shown to be is an important predictor of clinical outcomes in mechanical thrombectomy for acute ischemic stroke (AIS). In this study, we sought to assess the influence of TOR on outcomes in the multicenter, randomized Solitaire FR with the Intention for Thrombectomy (SWIFT) trial.

Methods: AIS patients enrolled in the SWIFT trial who achieved the primary endpoint of successful recanalization without hemorrhage (SR-sICH) were included. The TOR was the main predictor variable. The main outcome variables were the 90 days modified Rankin’s Scale (mRS) ≤ 2; good neurologic outcome (Rankin’s Scale (mRS) ≤ 2 or NIHSS Improvement of ≥10), and mortality. P-values were calculated using Wilcoxon, linear regression, Cochran Mantel-Haenzsel, or Fischer exact tests.

Results: A total of 63 patients achieved SR-sICH and were included in this analysis. 57% patients had a good clinical outcome of mRS ≤ 2, with a mean TOR of 310(74) minutes vs. 348(80) minutes in those with mRS>2 at 90 days, p=0.08. Patients who died (19%) had a statistically longer TOR than survivors (TOR of 270(75) minutes versus 320(75) minutes in the survivors, p=0.04). Patients in lower quartiles had a trend toward improved neurological outcome and mortality (p=0.2 and p=0.1). When dichotomizing TOR to ≤6.5 hours (n=50) versus >6.5 hours (n=13), a trend toward better clinical outcome was noted in the ≤ 6.5 hours group; mRS ≤ 2 at 90-day (46% vs. 17%, p=0.008); with a trend toward improved good neurological outcome and mRS at 90 days (66% and 55% with p=0.19 and p=0.1, respectively) with no difference in mortality. A multivariate analysis model for predicting mRS at 90 days showed TOR as a significant predictor of neurological outcome (p=0.02).

Conclusions: A shorter time from TOR is associated with improved functional neurological outcome at 90 days in revascularized SWIFT trial patients.

Abstract WP81: Outcomes Following X- and Y-Configuration Stent-Assisted Coil Embolization of 52 Complex Bifurcation Cerebral Aneurysms

Background: Wide-neck bifurcation cerebral aneurysms pose technical challenges in endovascular therapy. Intersecting stents are used with increasing frequency. Periprocedural, clinical, and mid-term angiographic outcomes of this approach are not well known. We report clinical and angiographic outcomes in our use of the X- and Y-configuration techniques.

Methods: We reviewed a retrospectively collected database to identify all aneurysm cases in which an X- or Y-configuration stent technique was used. Demographic, periprocedural and mid-term clinical and imaging data were collected. Outcomes included rate of thromboembolic events (TEE), intraoperative perforations (IOP), mortality, aneurysm residual at the time of the procedure and recurrence observed at follow-up.

Results: Among 807 cerebral aneurysms, we identified 52 aneurysms in 50 patients treated with X- or Y-configuration stent implantation. Mean age was 58 years (SD = 10) with 34 (65%) women. Aneurysm locations were basilar artery (n = 20), MCA (n = 13), ACA (n = 16), and ICA (n = 3). Mean aneurysm maximum diameter was 7.0 mm (SD 2.9) and the mean neck size was 4.5 mm (SD = 1.7). Fifty cases (96%) involved “Y” configuration, and two cases (4%) used an “X” configuration. Aneurysm catheterization technique was trans-stent in all cases (vs jailing). Interstices catheterization required a wire or catheter change in 13 (25%) cases. Immediate results revealed complete occlusion in 45 (86.5%), residual aneurysm in 3 (5.7%), and residual neck in 4 (7.7%). There were no mortalities, and 7 (13.5%) TEEs, of which 2 (4%) were symptomatic. There were 2 (4%) asymptomatic IOPs. Imaging follow-up was available for 40 (77%) cases, with mean interval from index procedure of 5.7 months. This mid-term outcome showed complete obliteration in 28 (70%) cases, residual neck in 8 (20%), and residual aneurysm in 4 (10%).

Conclusions: These results suggest that placement of intersecting stents in X- and Y-configurations for coil embolization of wide-neck bifurcation cerebral aneurysms is feasible and can be performed with acceptable procedural safety and good rates of aneurysm occlusion.

Idiopathic Intracranial Hypertension. A Systematic Analysis of Transverse Sinus Stenting

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a disorder characterized by signs and symptoms of increased intracranial pressure without structural cause seen on conventional imaging. Hallmark treatment after failed medical management, has been CSF shunting or optic nerve fenestration with the goal of treatment being preservation of vision. Recently, there have been multiple case reports and case series on dural sinus stenting for this disorder.

OBJECTIVE

We aim to review all published cases and case series of dural sinus stenting for IIH, with analysis of patient presenting symptoms, objective findings (CSF pressures, papilledema, pressure gradients across dural sinuses), follow-up of objective findings, and complications.

METHODS

A Medline search was performed to identify studies meeting pre-specified criteria of a case report or case series of patients treated with dural sinus stent placement for IIH. The manuscripts were reviewed and data was extracted.

RESULTS

A total of 22 studies were identified, of which 19 studies representing 207 patients met criteria and were included in the analysis. Only 3 major complications related to procedure were identified. Headaches resolved or improved in 81% of patients. Papilledema improved the (172/189) 90%. Sinus pressure decreased from an average of 30.3 to 15 mm Hg. Sinus pressure gradient decreased from 18.5 (n=185) to 3.2 mm Hg (n=172). Stenting had an overall symptom improvement rate of 87%.

CONCLUSION

Although all published case reports and case series are nonrandomized, the low complication and high symptom improvement rate make dural sinus stenting for IIH a potential alternative surgical treatment. Standardized patient selection and randomization trials or registry are warranted.

Revascularization grading in endovascular acute ischemic stroke therapy

BACKGROUND

Recanalization and angiographic reperfusion are key elements to successful endovascular and interventional acute ischemic stroke (AIS) therapy. Intravenous recombinant tissue plasminogen activator (rt-PA), the only established revascularization therapy approved by the US Food & Drug Administration for AIS, may be less effective for large artery occlusion. Thus, there is enthusiasm for endovascular revascularization therapies, which likely provide higher recanalization rates, and trials are ongoing to determine clinical efficacy and compare various methods. It is anticipated that clinical efficacy will be well correlated with revascularization of viable tissue in a timely manner.

METHOD

Reporting, interpretation, and comparison of the various revascularization grading methods require agreement on measurement criteria, reproducibility, ease of use, and correlation with clinical outcome. These parameters were reviewed by performing a Medline literature search from 1965 to 2011. This review critically evaluates current revascularization grading systems.

RESULTS AND CONCLUSION

The most commonly used revascularization grading methods in AIS interventional therapy trials are the thrombolysis in cerebral ischemia (TICI, pronounced "tissy") and thrombolysis in myocardial ischemia (TIMI) scores. Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme. Other grading systems may be used for research and correlation purposes. A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.

Complications of endovascular therapy for acute ischemic stroke and proposed management approach

Over the past decade, endovascular therapy has emerged as a promising therapeutic approach for select patients with acute ischemic stroke. However, the morbidity, mortality, and complication rates in intra-arterial recanalization trials are higher than in the National Institute of Neurological Disorders and Stroke trial of IV tissue plasminogen activator. This review discusses common complications associated with endovascular therapy for acute ischemic stroke, avoidance of complications, and management of some of the common complications.

Developing practice recommendations for endovascular revascularization for acute ischemic stroke

Guidelines have been established for the management of acute ischemic stroke; however, specific recommendations for endovascular revascularization therapy are lacking. Burgeoning investigation of endovascular revascularization therapies for acute ischemic stroke, rapid device development, and a diverse training background of the providers performing the procedures underscore the need for practice recommendations. This review provides a concise summary of the Society of Vascular and Interventional Neurology endovascular acute ischemic stroke roundtable meeting. This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns. It therefore provides an outline for the future development of multisociety guidelines and recommendations to improve patient selection, procedural management, and organizational strategies for revascularization therapies in acute ischemic stroke.

High-dose intra-arterial nicardipine results in hypotension following vasospasm treatment in subarachnoid hemorrhage

BACKGROUND

Intra-arterial (IA) nicardipine is often used to treat cerebral vasospasm associated with subarachnoid hemorrhage (SAH). While hypotension has been noted to be a dose-limiting side effect of intravenous infusions, this has seldom been reported for IA administration.

METHODS

We reviewed a consecutive series of patients who received IA nicardipine for SAH-associated vasospasm. Nicardipine was titrated to angiographic response, with blood pressure and intracranial pressure monitoring. We analyzed data using Wilcoxon signed rank, Student's t-test, Spearman's correlation, and χ(2) statistics as appropriate. A P value <0.05 was considered significant.

RESULTS

Thirty patients underwent 50 procedures in which nicardipine was the sole chemical vasodilator (median dose, 15 mg). Median mean arterial pressures (MAP) decreased from 118 to 100 mmHg (P < 0.001), with an intra-operative low of 80 mmHg. Both intra-operative and post-operative decreases in MAP were directly related to nicardipine dose (r (s) = 0.352, P = 0.022 and r (s) = 0.308, P = 0.047, respectively). Hypotension (MAP < 70 mmHg) occurred in 22%, and 44% required initiation of or increases in vasopressor therapy. After the first treatment, 11 of 16 patients treated with vasodilator therapy alone, and 5 of 14 patients who underwent additional balloon angioplasty (68.8 vs. 35.7%, P = 0.141), required further endovascular treatments due to recurrent vasospasm on subsequent days.

CONCLUSIONS

Intra-arterial nicardipine is associated with significant intra-operative blood pressure lowering, an increased requirement for intra-operative vasopressor therapy, and a tendency toward re-treatment when used as initial monotherapy for vasospasm.

Abstract 3747: Clinical And Imaging Outcomes For Target Aneurysm Retreatment For Remnant Intracranial Aneursym

Introduction: Aneurysmal subarachnoid hemorrhage (SAH) is a rare but devastating form of stroke. Currently surgical clipping and endovascular embolization are the two therapeutic options for treatment of intracerebral aneurysm. The reported complication rate associated with the initial endovascular treatment is about 2-40%. However, outcome and complications after target aneurysmal retreatment (TAR) is unknown. Our objective is to report clinical and imaging outcomes for TAR.

Design/Methods: We identified patients who underwent TAR from a hospital neurointerventional database. We collected data on demographics, peri-procedural complications, clinical and imaging outcomes at the discharge and last follow-up. Peri-procedural complications were reported as intra operative perforation (IOP), thromboembolic event (TEE), both were considered symptomatic if patient develop new neurological deficit lasting for increase in NIHSS . Length of hospital stay, modified Ranking Scale (mRS), discharge disposition, recurrent SAH, re-treatment of the same aneurysm, and mortality were measured at discharge and follow up appointments. Complete data was available for 115/155 (74%) cases.

Results: There were total of 155/1169 (13.3%) cases underwent TAR with mean age of 55 ( 3), 98 (63%) were females, and 118 (76%) were Caucasians. One hundred four (67%), had aneurysm located in the anterior circulation, 4/116 (3%) underwent TAR for recurrent acute SAH, 72/116 (62%) required stent and 10/116 (9%) required balloon assist. There were total of 5/115 (4%) IOP, and 8/115 (7%) TEE from which 2/115 (2%), and 1/115 (1%) were symptomatic respectively for a total of 3/115 (2.6%) patients. 117/151 (77%) had complete immediate obliteration of the aneurysm after TAR. Ninety five patients (83%) had mean length of hospital stay with 143/151 (95%) patients discharged home. At discharge 99/114 (87%) patients, had mRS with 0% mortality. Total of 90/155 (58%) patients had average follow up of 14 months with 8/90 (9%) requiring a 2 nd TAR and 1/90 (1%) requiring 3 rd TAR for recanalization. There was no re-rupture after the 1 st TAR for the duration of follow-up period of 14 ( in total of 90 patients).

Conclusions: In our study the rate of symptomatic events following TAR after initial endovascular therapy is 3/115 (2.6%) with 77% obliteration rate and 0% re-repture rate. TAR after an initial endovascular treatment is safe with an acceptable rate of complications and may be effective, suggested by lower rate of re-rupture.

Abstract 3554: GP IIb/IIIa Inhibitor Use during Endovascular Coil Embolization: A Single Center Experience

Introduction: Acute thromboembolic event (TEE) remains a considerable complication of endovascular aneurysm treatment. We sought to evaluate the safety of Glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors for TEE during endovascular aneurysm embolization (EAE).

Method: We reviewed a single-center retrospectively collected database of EAE from 7 / 2005 to 12/2010. All patients who received a GPIIb/IIIa inhibitor (abciximab or eptifibatide) were included in the analysis. Clinical, demographic, and radiographic data were retrospectively collected through chart review. TEE was defined as a partial or complete occlusion of the parent vessel at the aneurysm neck, and/or distal vessel within the parent vessel territory. Recanalization was defined as near-complete or complete resolution of vessel thrombus on angiogram. New intracerebral hemorrhage (ICH) was defined as new intraparenchymal hemorrhage finding on head CT or new area of subarachnoid hemorrhage (SAH) >1mm in thickness.

Result: Among a database of 701 cases, a GPIIb/IIIa inhibitor was used in a total of 61 (8.7%) cases, of these 57 were treated for TEE and 4 were treated prophylactically for sub therapeutic platelet point of care testing. There were 41 males, and the mean age was 54 ±13 years. The TEE occurred slightly higher during ruptured aneurysm coiling (57% and 43%, p=0.07). Thirty-nine (64%) cases were treated with adjunctive devices, which included a stent (29) or balloon (10), p-value=0.001. Close to half of the TEE was not occlusive (54%). A total of 55 (90%) cases received abciximab with a mean bodyweight base dose of 0.17mg/kg, and 6 (10%) cases received eptifibatide with a mean body weight base dose of 0.15mg/kg. Nine (16%) cases required additional therapy for ongoing clot (stent (3), balloon (3), penumbra (1), intra- arterial thrombolysis (1), and vessel sacrifice (1). Forty-two (74%) cases had complete angiographic recanalization (77% using abciximab and 25% using eptifibatide, (p=0.051)). There were 10 (16%) new ICH; 3 (5%) which were symptomatic. Patients with new ICH had non significant higher mean bodyweight dose compare to patients without new ICH 0.26 0.32 mg/kg and 0.15 0.07 mg/kg respectively.

Conclusion: GP IIb/IIIa inhibitor use in EAE as single and multimodal therapy for acute TEE may have acceptable safety and recanalization rates (symptomatic ICH of 5% and complete recanalization of 74%). Further study to confirm the current study findings and identify optimal dosing is needed; however these data suggest that a lower dose may be favorable.

Abstract 2225: Vertebral Artery Stenting for the Treatment of Bow Hunter Syndrome: a report of four cases

Background: Bow Hunter syndrome is a rare condition that results from vertebrobasilar insufficiency secondary to mechanical occlusion or stenosis of the vertebral artery due to head rotation. Traditionally, surgical intervention with C1-C2 fusion or decompression of the vertebral artery was the mainstay of therapy. Endovascular intervention was rarely described for the treatment of bow hunter syndrome.

Methods: The neurointerventional database between July 2005 and October 2010 was reviewed for identification of all cases of bow hunter syndrome that were treated with vertebral artery stenting. We report clinical, technical and outcome data on four patients with bow hunter syndrome who were treated with vertebral artery stenting.

Results: Vertebral artery stenting was performed in the V2 segment (C2-C6) of the vertebral arteries in all four patients without significant technical difficulties. All patients reported symptomatic relief with minor or no residual stenosis on dynamic digital subtraction angiography.

Conclusion: Vertebral artery stenting for the treatment of Bow Hunter syndrome is feasible, safe, and clinically effective. Endovascular techniques might offer an alternative and a minimally invasive therapy for the treatment of bow hunter syndrome. Figure 1 . Case #1. (A) Selective left subclavian angiogram showing the left vertebral artery with head in neutral position. (B) Narrowing of the V2 segment with head turned to the left. (C) Post-stenting of the V1 (origin) and V2 segments with head turned to the left.

Abstract 2884: Angiographic Lumen Changes From Oversized Neuroform Stent Implantation

Introduction: The effect of oversized intracranial stent implantation, and the potential for excessive neointimal hyperplasia from the resulting chronic outward radial force, has not been previously reported. We sought to compare the angiographic narrowing associated with implantation of oversized Neuroform stents overlapping vessels of different diameters.

Methods: We reviewed an aneurysm database and identified patients treated with stent-assisted coil embolization involving stent placement overlapping a vessel size transition. Patient demographics and lesion characteristics were extracted from chart review. A submillimeter digital caliper was used for angiogram measurement of lumen diameter at four sites ( figure ). The relationship between lumen diameter and stent oversizing was compared with student’s t-test and Pearson’s correlation.

Results: Twenty vessels were identified in 18 patients, providing 80 paired data points. Mean age was 52 years (SD 12), with mean follow-up time of 8 months (SD 6). The distribution of vessel transitions included BA to PCA (n = 8), A1 to A2 or M1 to M2 (n = 8), ICA to ACA or MCA (n = 3), and Vertebral artery to PICA (n = 1). Stent diameter ranged from 3 mm to 4.5 mm, and the average oversizing in the smaller diameter parent vessel landing-zone was 1.75 mm (range 0.8 to 2.9 mm) greater than the vessel diameter. The mean change in lumen size from pre-stent implantation to follow-up was not significantly different for any of the four sites; the proximal end-stent decreased by 5.5% (SD 19.7), proximal mid-stent increased by 7.3% (SD 18.8), distal mid-stent increased by 14.7% (SD 13.8), and the distal end-stent decreased by 0.9% (SD 13.1). Stent oversizing by less than a factor of 1.65 resulted in a mean lumen loss of 4.1% (SD 15.6), while oversizing by greater than a factor of 1.65 resulted in a mean lumen gain of 11.1% (SD = 17.2), (p = 0.006).

Conclusions: These data suggest oversized Neuroform stent implantation within the intracranial vasculature does not lead to increased stenosis. Stent oversizing by a factor of 1.65 or more leads to significant persistent luminal gain. The non-significant trend toward lumen loss at the stent tines suggests diminished radial force or greater neointimal hyperplasia at these sites, however persistent luminal gain from the oversized stent radial force likely predominates over any neointimal hyperplasia. Figure . A NF stent overlapping the M1 and M2 segments (A, tines indicated by white arrows). Four points of measurement (B), proximal tines (1.), mid-stent in proximal landing zone (2.), mid-stent in distal landing zone (3.), and distal tines (4.).

Pericallosal artery aneurysm treatment using Y-configuration stent-assisted coil embolization: a report of four cases

BACKGROUND

Pericallosal artery aneurysms at the bifurcation represent a special endovascular technical challenge given their distal location, commonly wide-neck morphology, small parent vessel diameter and potentially high recurrence rate after coiling given the bifurcation location. Y-configuration stent-assisted coil embolization techniques have been reported for the treatment of wide-neck aneurysms located at other vascular bifurcations and only rarely with A2 bifurcation aneurysms.

METHODS

A neurointerventional database was reviewed for identification of all cases of A2 bifurcation aneurysms that were treated with Y-stent configuration. The authors report clinical, technical and outcome data on four patients with pericallosal aneurysms who were treated with a Y-configuration stent-assisted coil embolization technique.

RESULTS

A Y-configuration stent placement in the anterior cerebral artery/A2 bifurcation was successfully achieved in all four patients without significant technical difficulties. One patient presented with a previously ruptured and partially treated aneurysm and three patients with incidentally found aneurysms. All four patients had a Y-configuration stent placement in one setting. The Y-configuration allowed for complete occlusion of all four aneurysms with no recurrence or arterial occlusion on mean angiographic follow-up of 13.5 months (6-28).

CONCLUSION

Treating wide-neck pericallosal artery aneurysms at the bifurcation with Y-configuration stent placement is feasible and effective. This technique may be considered as a therapeutic option for wide-neck aneurysms that pose a difficult technical challenge.

X-configuration intersecting Enterprise stents for vascular remodeling and assisted coil embolization of a wide neck anterior communicating artery aneurysm

BACKGROUND

Intracranial stent technology and techniques have expanded the applications of endovascular therapy for complex intracranial aneurysms. Various methods of stent assisted coil embolization have been described. An additional technique of X-configuration intersecting Enterprise stent implantation with trans-stent microcatheterization for the treatment of a wide neck anterior communicating artery aneurysm is presented.

RESULTS

Successful X-configuration intersecting stent implantation and coil embolization of a wide neck aneurysm is reported with no perioperative complications.

CONCLUSIONS

The technique of trans-stent microcatheterization with X-configuration intersecting Enterprise stent implantation for the treatment of wide neck anterior communicating artery aneurysms is technically feasible. Further study is needed to evaluate technical success, procedural outcome and long term angiographic results.

Endovascular embolization of head and neck tumors

Endovascular tumor embolization as adjunctive therapy for head and neck cancers is evolving and has become an important part of the tools available for their treatment. Careful study of tumor vascular anatomy and adhering to general principles of intra-arterial therapy can prove this approach to be effective and safe. Various embolic materials are available and can be suited for a given tumor and its vascular supply. This article aims to summarize current methods and agents used in endovascular head and neck tumor embolization and discuss important angiographic and treatment characteristics of selected common head and neck tumors.

Initial experience with the coaxial dual-lumen ascent balloon catheter for wide-neck aneurysm coil embolization

Introduction: Techniques for coil embolization of wide-neck cerebral aneurysms include the use of stents and temporary occlusion with compliant non-detachable balloons to safely allow dense packing of the aneurysm lumen with detachable coils. We describe the use of a new balloon device for assisting in wide-neck aneurysm coil treatment. Methods: A single institution neuroendovascular database was accessed to identify cases in which the Ascent balloon (Codman Neurovascular, Raynham, MA, USA) was used for aneurysm coil embolization. Clinical, demographic, and angiographic data were obtained through chart review. Results: Eleven cerebral aneurysm cases were treated using the Ascent balloon during the first 12-month period that the new device was available at our institution. Three of the patients presented with ruptured aneurysms. All aneurysms were large (maximum diameter 6 mm or greater), with an average maximum diameter of 9.4 mm, and an average neck diameter of 5.5 mm. Complete occlusion with coil embolization (Raymond class I) was achieved in all cases. The Ascent balloon was successfully positioned across the neck of the aneurysm in nine patients. Conclusion: This initial experience demonstrates the feasibility and immediate outcomes of the coaxial dual-lumen design Ascent balloon catheter used as an assistive device in coil embolization of wide-neck cerebral aneurysms. This device contributes to the growing number of assistive devices for the treatment of complex cerebral aneurysms.

Endovascular therapy for chronic cerebrospinal venous insufficiency in multiple sclerosis

Recent reports have emerged suggesting that multiple sclerosis (MS) may be due to abnormal venous outflow from the central nervous system, termed chronic cerebrospinal venous insufficiency (CCSVI). These reports have generated strong interest and controversy over the prospect of a treatable cause of this chronic debilitating disease. This review aims to describe the proposed association between CCSVI and MS, summarize the current data, and discuss the role of endovascular therapy and the need for rigorous randomized clinical trials to evaluate this association and treatment.

Dissecting aneurysms of posterior cerebral artery: clinical presentation, angiographic findings, treatment, and outcome

BACKGROUND

The dissecting posterior cerebral artery (PCA) aneurysms are very rare. These aneurysms pose significant treatment challenge and need careful evaluation to formulate an optimal treatment plan in case of ruptured or un-ruptured presentations.

METHODS

Retrospective review of a prospectively collected data.

RESULTS

Seven patients with dissecting aneurysms of the PCA were identified. Six out of seven presented with subarachnoid hemorrhage (SAH) and one with ischemic stroke. Three out of seven were treated with endovascular coil embolization without sacrifice of the parent artery and the rest had parent artery occlusion (PAO) with coil embolization. None of the patients developed new neurological deficits post-procedure. Aneurysm re-occurred in two patients that were treated without PAO.

CONCLUSION

Endovascular treatment of the dissecting PCA aneurysm is safe and feasible. It can be performed with or without PAO. Recurrence is more common without PAO and close follow-up is warranted.

Moyamoya syndrome in an adult with essential thrombocythemia

Moyamoya syndrome is a rare cerebrovascular disorder characterized by progressive occlusion of the supraclinoid internal carotid artery and proximal portions of the anterior and middle cerebral arteries resulting in an extensive network of collateralized blood vessels and producing a characteristic angiographic appearance. Although the pathophysiology is unclear, hematologic disorders have been associated with development of the moyamoya syndrome. A case report is presented. A 29 year-old female with a history of essential thrombocythemia developed progressive ischemic strokes. Angiography revealed characteristic moyamoya changes and pathologic examination showed intimal hyperplasia with scant collagen fibers and myxoid change. This is the first reported case of moyamoya syndrome in an adult patient with essential thrombocythemia demonstrating histological findings that suggest a shared pathophysiology with moyamoya syndrome in sickle cell anemia.

Stroke severity predicted by aortic atheroma detected by ultra-fast and cardiac-gated chest tomography

Background and Purpose: The presence of aortic atherosclerosis is an independent risk factor for secondary stroke. The present study was designed to have an initial exploration of the correlation between the load and extent of aortic atheroma (AA) and initial stroke severity or clinical outcome 3 months after stroke. Methods: Cardiac-gated chest tomography (CGCT) was used to detect and measure AA in patients with acute ischemic stroke as shown by our group in prior prospective studies and this is part four sub-exploratory study of the same cohort. The National Institute of Health Stroke Scale (NIHSS) was used to assess the initial stroke severity, and the modified Rankin Scale (mRS) was used to assess 3-month outcome. Results: Thirty-two patients underwent CGCT for evaluation of AA, and 21 were found to have AA. AA was more prevalent in patient with NIHSS >6 (14/17 versus 7/15, p-value 0.03). Applying the multiple logistic regression and propensity score adjustment (using the propensity of having AA given the baseline features as covariates) showed a non-significant trend that AA is three times more likely to be associated with NIHSS >6 (p = 0.08, OR 3.08, 95% CI 0.94–13.52). There was no evidence of association of AA with 3-month functional outcome (mRS): 11/14 (78.6%) mRS >1 had AA, and 10/18 (55.5%) of those with mRS ≤1 had AA (p = 0.27). Conclusion: In our current study with limited sample number and exploratory nature, the presence of AA on CGCT with acute ischemic stroke patients may be associated with worse neurological deficit at presentation. There was no evidence of association with 3-month functional outcome using the mRS.

Induced hypothermia in acute ischemic stroke

BACKGROUND

Induced hypothermia is a promising neuroprotective treatment for acute ischemic stroke. Data from both global and focal ischemia animal models have been encouraging. However, only a few small clinical studies have investigated its use in humans.

OBJECTIVE

To review the background, possible mechanisms of action, and the preclinical and clinical data supporting the neuroprotective role of induced hypothermia following acute ischemic stroke.

METHODS

A literature search was performed using the PubMed database. Only papers in English were reviewed.

RESULTS/CONCLUSIONS

Induced hypothermia is effective as a neuroprotectant in animal models of acute ischemic stroke. Its multimodal mechanism of action makes it a very attractive method of neuroprotection. Although human studies suggest it is safe and feasible, larger randomized controlled trials are necessary to address clinical efficacy and to refine the methods and parameters of induced hypothermia protocols.

Hexosamines regulate leptin production in 3T3-L1 adipocytes through transcriptional mechanisms

This study was undertaken to examine the regulation of leptin gene (LEP) transcription and leptin release by hexosamines in 3T3-L1 adipocytes. Glucosamine (1 mM), an intermediate in hexosamine biosynthesis, increased leptin release to 117.0 +/- 7.3% (P = 0.0430; n = 9) and 134.6 +/- 6.5% of the control value (P = 0.0367; n = 4) by 48 and 96 h, respectively. With 0.01 mM glucosamine, leptin release was increased to 120.0 +/- 3.0% of the control value (P = 0.0069; n = 4) by 96 h of treatment. Glucose at 5 and 20 mM stimulated leptin release to 759 +/- 227% and 1104 +/- 316% of the control value over the 96-h culture period. Inhibition of hexosamine biosynthesis with 6-diazo-5-oxonorleucine (20 microM) reduced glucose-stimulated leptin release 13 +/- 2.3% and 29.9 +/- 6.6% at 24 and 96 h, respectively (n = 4; P < 0.05). A 24-h incubation in 5 mM glucose significantly increased (163.0 +/- 19.3%; n = 7) the activity of a human LEP promoter electroporated into differentiated 3T3-L1 cells. Glucosamine (1 mM; 48 h) also increased LEP promoter activity 170.0 +/- 13.0% (n = 5). Mutation of the three Sp1 binding sites in the LEP construct significantly reduced promoter activity. However, glucose (5 mM; 24 h) and glucosamine (1 mM; 48 h) increased the activity of the mutated promoter to 165 +/- 40% (n = 8) and 143 +/- 13% of the control value (n = 8). Glucosamine significantly increased O-glycosylation of Sp1 by 16.1 +/- 4.5% (P = 0.0305; n = 3). These data demonstrate that glucose and hexosamines regulate leptin production through transcriptional mechanisms localized to the proximal portion of the LEP promoter. Hexosamine-mediated regulation of LEP gene expression does not depend on Sp1 binding to traditional sites on the promoter.

Cloning and characterization of the murine Imitation Switch (ISWI) genes: differential expression patterns suggest distinct developmental roles for Snf2h and Snf2l

Here we report the cloning of two cDNAs, Snf2h and Snf2l, encoding the murine members of the Imitation Switch (ISWI) family of chromatin remodeling proteins. To gain insight into their function we examined the spatial and temporal expression patterns of Snf2h and Snf2l during development. In the brain, Snf2h is prevalent in proliferating cell populations whereas, Snf2l is predominantly expressed in terminally differentiated neurons after birth and in adult animals, concomitant with the expression of a neural specific isoform. Moreover, a similar proliferation/differentiation relationship of expression for these two genes was observed in the ovaries and testes of adult mice. These results are consistent with a role of Snf2h complexes in replication-associated nucleosome assembly and suggest that Snf2l complexes have distinct functions associated with cell maturation or differentiation.

A novel cdc2-related protein kinase expressed in the nervous system

We report the cloning and characterization of a cDNA encoding a cdc2-related protein kinase, named PFTAIRE, that is expressed primarily in the postnatal and adult nervous system. We have demonstrated by in situ hybridization and indirect immunofluorescence that several populations of terminally differentiated neurons and some neuroglia expressed PFTAIRE mRNA and protein. In neurons, PFTAIRE protein was localized in the nucleus and cytoplasm of cell bodies. The anatomical, cellular, and ontogenic patterns of PFTAIRE expression in the nervous system differed from those of p34cdc2 and cdk5, which are expressed in brain and several other mitotic tissues. Proteins of approximately 58-60 kDa coprecipitated specifically with PFTAIRE from cytosolic protein preparations of adult mouse brain and transfected cells. These proteins appeared to be the major endogenous substrates associated with this kinase activity. The temporal and spatial expression patterns of PFTAIRE in the postnatal and adult nervous system suggest that PFTAIRE kinase activity may be associated with the postmitotic and differentiated state of cells in the nervous system and that its function may be distinct from those of p34cdc2 and cdk5.