Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.104
J. Carrión-Penagos, R. Morsi, A. Tarabichi, S. Thind, S. Kothari, H. Desai, E. Coleman, J. Brorson, S. Mendelson, C. Kramer, F. Goldenberg, S. Prabhakaran, A. Mansour, T. Kass-Hout
Chronic subdural hematomas (SDH) have a higher prevalence among the elderly population and can cause significant morbidity and mortality when they recur after surgical intervention. Use of n‐butyl‐2‐cyanoacrylate (n‐BCA) has proven to be an effective and safe therapeutic agent for embolization of the middle meningeal artery (MMA). In our study, we present a retrospective analysis of 31 patients who underwent MMA embolization for chronic SDH. In a prospectively maintained database in a single center, we retrospectively analyzed 31 patients admitted to our institution who were diagnosed with chronic SDH, acute on chronic SDH, and acute SDH, and underwent MMA embolization with n‐BCA between May 20th, 2021, and June 28th, 2022. Our primary endpoint was >50% SDH reduction on follow‐up imaging. Our secondary endpoint was all‐cause mortality. Patients were separated into outcome groups and their baseline demographic, clinical, and procedural variables were compared using t‐test, Wilcoxon rank‐sum test, chi‐squared test, and Fisher’s exact test. Through univariate logistic regression, we attempted to determine if these variables directly influenced SDH reduction and mortality. In our study, a total of 42 MMA embolizations for 31 patients were included. We found that a greater number of patients with hypertension (n = 23; p = 0.04), use of antiplatelet (AP) medication (n = 8; p = 0.02), and those who underwent MMA embolization via the radial approach (n = 18; p = 0.004) were among those with < 50% SDH reduction. We also found that MMA embolization via the femoral approach (n = 13; p = 0.004) were more likely seen in those with >50% SDH reduction. The mean fluoroscopy time was longer in patients with >50% SDH reduction compared to those with < 50% reduction (43.2 minutes vs. 28.2 minutes, respectively; p = 0.03). On linear regression analysis, history of hypertension showed a non‐significant trend towards < 50% resolution of SDH (OR 5.67; 95% CI 0.99, 32.43; p = 0.05). Femoral approach for MMA embolization was associated with >50% of hematoma reduction (OR 12.00; 95% CI 1.89, 76.38; p = 0.004). Longer fluoroscopy time showed the same association (OR 1.05, 95% CI 1.00, 1.11; p = 0.03). All‐cause mortality was seen in 6 of the 31 patients, none of them associated with the SDH or the n‐BCA embolization procedure with no significant difference between groups. MMA embolization with n‐BCA appears to be an effective and safe method for management of SDH as has been shown in prior retrospective studies. Our small sample size may underestimate the effect some variables have on radiographic and clinical outcomes. Hypertension and use of AP seem to play a role in hematoma resolution; however, a bigger cohort is needed to confirm these hypotheses. Femoral approach and longer fluoroscopy time were associated with hematoma resolution, but other variables should be considered to rule out any procedure‐related confounders. Future randomized contro
{"title":"Abstract Number ‐ 104: Outcomes after middle meningeal artery embolization using n‐butyl‐2 cyanoacrylate for subdural hematomas: a case‐series","authors":"J. Carrión-Penagos, R. Morsi, A. Tarabichi, S. Thind, S. Kothari, H. Desai, E. Coleman, J. Brorson, S. Mendelson, C. Kramer, F. Goldenberg, S. Prabhakaran, A. Mansour, T. Kass-Hout","doi":"10.1161/svin.03.suppl_1.104","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.104","url":null,"abstract":"\u0000 \u0000 Chronic subdural hematomas (SDH) have a higher prevalence among the elderly population and can cause significant morbidity and mortality when they recur after surgical intervention. Use of n‐butyl‐2‐cyanoacrylate (n‐BCA) has proven to be an effective and safe therapeutic agent for embolization of the middle meningeal artery (MMA). In our study, we present a retrospective analysis of 31 patients who underwent MMA embolization for chronic SDH.\u0000 \u0000 \u0000 \u0000 In a prospectively maintained database in a single center, we retrospectively analyzed 31 patients admitted to our institution who were diagnosed with chronic SDH, acute on chronic SDH, and acute SDH, and underwent MMA embolization with n‐BCA between May 20th, 2021, and June 28th, 2022. Our primary endpoint was >50% SDH reduction on follow‐up imaging. Our secondary endpoint was all‐cause mortality. Patients were separated into outcome groups and their baseline demographic, clinical, and procedural variables were compared using t‐test, Wilcoxon rank‐sum test, chi‐squared test, and Fisher’s exact test. Through univariate logistic regression, we attempted to determine if these variables directly influenced SDH reduction and mortality.\u0000 \u0000 \u0000 \u0000 In our study, a total of 42 MMA embolizations for 31 patients were included. We found that a greater number of patients with hypertension (n = 23; p = 0.04), use of antiplatelet (AP) medication (n = 8; p = 0.02), and those who underwent MMA embolization via the radial approach (n = 18; p = 0.004) were among those with < 50% SDH reduction. We also found that MMA embolization via the femoral approach (n = 13; p = 0.004) were more likely seen in those with >50% SDH reduction. The mean fluoroscopy time was longer in patients with >50% SDH reduction compared to those with < 50% reduction (43.2 minutes vs. 28.2 minutes, respectively; p = 0.03). On linear regression analysis, history of hypertension showed a non‐significant trend towards < 50% resolution of SDH (OR 5.67; 95% CI 0.99, 32.43; p = 0.05). Femoral approach for MMA embolization was associated with >50% of hematoma reduction (OR 12.00; 95% CI 1.89, 76.38; p = 0.004). Longer fluoroscopy time showed the same association (OR 1.05, 95% CI 1.00, 1.11; p = 0.03). All‐cause mortality was seen in 6 of the 31 patients, none of them associated with the SDH or the n‐BCA embolization procedure with no significant difference between groups.\u0000 \u0000 \u0000 \u0000 MMA embolization with n‐BCA appears to be an effective and safe method for management of SDH as has been shown in prior retrospective studies. Our small sample size may underestimate the effect some variables have on radiographic and clinical outcomes. Hypertension and use of AP seem to play a role in hematoma resolution; however, a bigger cohort is needed to confirm these hypotheses. Femoral approach and longer fluoroscopy time were associated with hematoma resolution, but other variables should be considered to rule out any procedure‐related confounders. Future randomized contro","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45447529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.169
T. Imahori, S. Tateshima, N. Kaneko
The characteristics of the occlusive clot affect the clot integration with a stent retriever (SR). This relationship, stent‐clot interaction, is considered to be a major factor in the technical success of mechanical thrombectomy. To date, numerous studies analyzing the retrieved clots have shown that both soft erythro‐rich clots and hard fibrin‐rich clots make clot retrieval challenging. Several studies have successfully obtained information on this interaction using three‐dimensional (3D) rotational angiography. However, these 3D imaging technologies have not been utilized in clinical practice due to the time‐consuming nature of image acquisition and processing. Our previous clinical study demonstrated that the angiographic findings about the deployed stent morphology obtained from conventional two‐dimensional (2D) angiography could predict recanalization (1). The greater stent expansion at the occlusion was strongly associated with recanalization after the procedure. This intraprocedural angiographic sign allows us to know the stiffness of the clots in real‐time and to choose the optimal technique. The purpose of this study was to evaluate whether the stent expansion assessed by a 2D angiographical image reflects the actual stent dilation at the occlusion (Figure). We investigated the correlations between 2D images and 3D structures of the deployed SR using an experimental occlusion model. Using occlusion models created with pseudo‐clot with 9 hardness levels (n = 3/clot type), images of the deployed Trevo SR were obtained by cone‐beam computed tomography.As the measurement metric for the 2D images, we used the degree of stent expansion obtained from a plane along the long axis of the device. In clinical practice, however, this 2‐D image is usually obtained from one viewing angle. Therefore, to investigate the difference in measurement by viewing angle, different angle 2D images were created to evaluate the stent expansion. For the 3D structures, we used the stent area obtained from the short‐axis plane of the vascular model, considering this as a surrogate for actual stent expansion. We evaluated the correlation between the 2D images and the 3D structure. A total of 27 model image sets were obtained, showing graduated stent expansion (range: 21–79%) depending on the clot type. The median variation in the degree of stent expansion for each model measured at different angles, which means the differences by viewing angles, was 9% (range: 5–20%). The median degree of stent expansion was strongly correlated with the stent area (Pearson’s coefficient: 0.98), indicating that the degree of stent expansion could reflect the 3D structure. This study showed that the stent expansion on 2D angiography, even assessed from one direction, could be used as the approximation of the actual stent dilatation at the occlusion. This angiographic sign provides real‐time feedback on the clot characteristics at the occlusion.
{"title":"Abstract Number ‐ 169: Intraprocedural angiographic sign for assessing the stent‐clot interaction during mechanical thrombectomy","authors":"T. Imahori, S. Tateshima, N. Kaneko","doi":"10.1161/svin.03.suppl_1.169","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.169","url":null,"abstract":"\u0000 \u0000 The characteristics of the occlusive clot affect the clot integration with a stent retriever (SR). This relationship, stent‐clot interaction, is considered to be a major factor in the technical success of mechanical thrombectomy. To date, numerous studies analyzing the retrieved clots have shown that both soft erythro‐rich clots and hard fibrin‐rich clots make clot retrieval challenging. Several studies have successfully obtained information on this interaction using three‐dimensional (3D) rotational angiography. However, these 3D imaging technologies have not been utilized in clinical practice due to the time‐consuming nature of image acquisition and processing. Our previous clinical study demonstrated that the angiographic findings about the deployed stent morphology obtained from conventional two‐dimensional (2D) angiography could predict recanalization (1). The greater stent expansion at the occlusion was strongly associated with recanalization after the procedure. This intraprocedural angiographic sign allows us to know the stiffness of the clots in real‐time and to choose the optimal technique. The purpose of this study was to evaluate whether the stent expansion assessed by a 2D angiographical image reflects the actual stent dilation at the occlusion (Figure). We investigated the correlations between 2D images and 3D structures of the deployed SR using an experimental occlusion model.\u0000 \u0000 \u0000 \u0000 Using occlusion models created with pseudo‐clot with 9 hardness levels (n = 3/clot type), images of the deployed Trevo SR were obtained by cone‐beam computed tomography.As the measurement metric for the 2D images, we used the degree of stent expansion obtained from a plane along the long axis of the device. In clinical practice, however, this 2‐D image is usually obtained from one viewing angle. Therefore, to investigate the difference in measurement by viewing angle, different angle 2D images were created to evaluate the stent expansion. For the 3D structures, we used the stent area obtained from the short‐axis plane of the vascular model, considering this as a surrogate for actual stent expansion. We evaluated the correlation between the 2D images and the 3D structure.\u0000 \u0000 \u0000 \u0000 A total of 27 model image sets were obtained, showing graduated stent expansion (range: 21–79%) depending on the clot type. The median variation in the degree of stent expansion for each model measured at different angles, which means the differences by viewing angles, was 9% (range: 5–20%). The median degree of stent expansion was strongly correlated with the stent area (Pearson’s coefficient: 0.98), indicating that the degree of stent expansion could reflect the 3D structure.\u0000 \u0000 \u0000 \u0000 This study showed that the stent expansion on 2D angiography, even assessed from one direction, could be used as the approximation of the actual stent dilatation at the occlusion. This angiographic sign provides real‐time feedback on the clot characteristics at the occlusion.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45481862","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.126
A. Rodriguez-Calienes, J. Vivanco-Suarez, M. Galecio-Castillo, M. Malaga, Cynthia B. Zevallos, M. Farooqui, C. Morán-Mariños, N. Fanning, O. Algın, B. Pabon, N. Mouchtouris, P. Jabbour, S. Ortega‐Gutierrez
The Woven EndoBridge (WEB) device was originally approved to treat intracranial wide‐necked saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of intracranial aneurysms (IA) in alternative locations with variable success. We aimed to evaluate the safety and efficacy of the WEB for IAs in off‐labeled locations using a meta‐analysis (MA) of the literature. We performed a systematic review of all studies including patients treated with WEB for IAs in locations different than what is currently on‐label FDA until May 2022. Our primary efficacy and safety outcomes were adequate occlusion at last follow up and a composite of intraprocedural and postprocedural complications, respectively. The Raymond‐Roy (RR) scale and the Bicêtre Occlusion Scale Score (BOSS) were used to define complete (RR: 1; BOSS: 0‐0’) and adequate (RR:1‐2; BOSS: 0–2) occlusion. Additional safety outcomes included intraprocedural (thromboembolic, hemorrhagic, device deployment, or air embolism) and postprocedural (ischemic or hemorrhagic) complications, and mortality. We performed a random‐effects MA of proportions and assessed the certainty of the evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I2 statistics. Logistic regression of the patient level data was used to study the predictors of complete occlusion. Ten studies were selected, and 285 patients (79% female; mean age 58 years) with 288 aneurysms (35% ruptured) were included. Adequate and complete occlusion rates were 89% (95% CI 81–94%; I2 = 0%; moderate‐certainty evidence) and 64% (95% CI 57–70%; I2 = 13%; moderate‐certainty evidence), respectively. The composite safety outcome rate was 8% (95% CI 3–17%; I2 = 34%; very low‐certainty evidence). The intraprocedural and postprocedural complication rates were 6% (95% CI 4–10%; I2 = 0%; very low‐certainty evidence) and 1% (95% CI 0–1%; I2 = 33%; very low‐certainty evidence), respectively. The mortality rate was 2% (95% CI 1–7%; I2 = 0%; very low‐certainty evidence). Aneurysm width (OR = 0.5; p = 0.03) was the only significant predictor of complete occlusion. The preliminary studies evaluating the use of WEB for the treatment of IAs in off‐labeled locations has demonstrated rates of adequate occlusion and procedural complications comparable to the landmark studies that evaluated the use of the WEB for on‐label bifurcation aneurysms. Given the level of evidence, we consider the interpretation of our results should be done cautiously until confirmation from larger prospective studies are obtained.
Woven EndoBridge (WEB)装置最初被批准用于治疗颅内宽颈囊状分叉动脉瘤。最近的研究表明，它用于治疗颅内动脉瘤(IA)在不同的位置有不同的成功。我们的目的是通过文献荟萃分析(MA)来评估WEB治疗非标签部位IAs的安全性和有效性。截至2022年5月，我们对所有研究进行了系统回顾，包括在不同地点接受WEB治疗的IAs患者，而不是目前FDA的标签。我们的主要疗效和安全性结果分别是充分的闭塞和术中及术后并发症的综合。使用Raymond‐Roy (RR)量表和Bicêtre闭塞量表评分(BOSS)来定义完全性(RR: 1;BOSS: 0‐0 ')和充足(RR:1‐2;BOSS: 0-2)遮挡。其他安全性结果包括术中(血栓栓塞、出血、器械部署或空气栓塞)和术后(缺血性或出血)并发症和死亡率。我们进行了随机效应MA比例分析，并使用GRADE方法评估了证据的确定性。采用I2统计评估各研究的统计异质性。采用患者水平数据的逻辑回归来研究完全闭塞的预测因素。10项研究入选，285例患者(79%为女性;平均年龄58岁，288个动脉瘤(35%破裂)。充分和完全的闭塞率为89% (95% CI 81-94%;i2 = 0%;中等确定性证据)和64% (95% CI 57-70%;i2 = 13%;中等确定性证据)。复合安全转归率为8% (95% CI 3-17%;i2 = 34%;极低确定性证据)。术中及术后并发症发生率为6% (95% CI 4-10%;i2 = 0%;极低确定性证据)和1% (95% CI 0-1%;i2 = 33%;极低确定性证据)。死亡率为2% (95% CI 1-7%;i2 = 0%;极低确定性证据)。动脉瘤宽度(OR = 0.5;P = 0.03)是完全闭塞的唯一显著预测因子。评估使用WEB治疗未标记位置的IAs的初步研究表明，充分闭塞和程序性并发症的发生率与评估使用WEB治疗未标记位置的分支动脉瘤的里程碑式研究相当。鉴于证据的水平，我们认为在获得更大规模的前瞻性研究的证实之前，我们的结果的解释应该谨慎进行。
{"title":"Abstract Number ‐ 126: Use of Woven EndoBridge device for Aneurysms in Off‐Labeled Locations: Systematic Review and Meta‐Analysis","authors":"A. Rodriguez-Calienes, J. Vivanco-Suarez, M. Galecio-Castillo, M. Malaga, Cynthia B. Zevallos, M. Farooqui, C. Morán-Mariños, N. Fanning, O. Algın, B. Pabon, N. Mouchtouris, P. Jabbour, S. Ortega‐Gutierrez","doi":"10.1161/svin.03.suppl_1.126","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.126","url":null,"abstract":"\u0000 \u0000 The Woven EndoBridge (WEB) device was originally approved to treat intracranial wide‐necked saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of intracranial aneurysms (IA) in alternative locations with variable success. We aimed to evaluate the safety and efficacy of the WEB for IAs in off‐labeled locations using a meta‐analysis (MA) of the literature.\u0000 \u0000 \u0000 \u0000 We performed a systematic review of all studies including patients treated with WEB for IAs in locations different than what is currently on‐label FDA until May 2022. Our primary efficacy and safety outcomes were adequate occlusion at last follow up and a composite of intraprocedural and postprocedural complications, respectively. The Raymond‐Roy (RR) scale and the Bicêtre Occlusion Scale Score (BOSS) were used to define complete (RR: 1; BOSS: 0‐0’) and adequate (RR:1‐2; BOSS: 0–2) occlusion. Additional safety outcomes included intraprocedural (thromboembolic, hemorrhagic, device deployment, or air embolism) and postprocedural (ischemic or hemorrhagic) complications, and mortality. We performed a random‐effects MA of proportions and assessed the certainty of the evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I2 statistics. Logistic regression of the patient level data was used to study the predictors of complete occlusion.\u0000 \u0000 \u0000 \u0000 Ten studies were selected, and 285 patients (79% female; mean age 58 years) with 288 aneurysms (35% ruptured) were included. Adequate and complete occlusion rates were 89% (95% CI 81–94%; I2 = 0%; moderate‐certainty evidence) and 64% (95% CI 57–70%; I2 = 13%; moderate‐certainty evidence), respectively. The composite safety outcome rate was 8% (95% CI 3–17%; I2 = 34%; very low‐certainty evidence). The intraprocedural and postprocedural complication rates were 6% (95% CI 4–10%; I2 = 0%; very low‐certainty evidence) and 1% (95% CI 0–1%; I2 = 33%; very low‐certainty evidence), respectively. The mortality rate was 2% (95% CI 1–7%; I2 = 0%; very low‐certainty evidence). Aneurysm width (OR = 0.5; p = 0.03) was the only significant predictor of complete occlusion.\u0000 \u0000 \u0000 \u0000 The preliminary studies evaluating the use of WEB for the treatment of IAs in off‐labeled locations has demonstrated rates of adequate occlusion and procedural complications comparable to the landmark studies that evaluated the use of the WEB for on‐label bifurcation aneurysms. Given the level of evidence, we consider the interpretation of our results should be done cautiously until confirmation from larger prospective studies are obtained.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45774558","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.058
Hayato Uchikawa, H. Takao, S. Fujimura, Tomoki Kasai, Shota Sunami, Kazuya Yuzawa, T. Ishibashi, K. Fukudome, M. Yamamoto, Y. Murayama
Although low volume embolization ratio is known as risk factor of aneurysmal recanalization, stable occlusion can be achieved in limited cases. Evaluation of hemodynamic parameters at the neck surface has usually been performed with a flat surface rather than a curved surface following the actual coil shape. In this study, we investigated the effect of the geometry of the neck surface on hemodynamics related to aneurysm recanalization after coil embolization in low volume embolization ratio. We focused on aneurysms of 5–10 mm in size that were conducted coil embolization with 15–20% volume embolization ratio (low‐VER). Aneurysms that were recanalized after coil embolization and conducted additional coil deployment were defined as the recanalized case. We identified 25 aneurysms (7 recanalized and 18 stable). We randomly selected 3 recanalized cases and 6 stable cases. For each case, the three‐dimensional vascular geometry including aneurysm was reconstructed by preoperative angiographic images. To divide the aneurysm from the parent artery, two types of neck surfaces (flat neck surface and curved neck surface) were generated for each case. The embolized coil was modeled in the enclosed area with the neck plane and aneurysmal wall by our original virtual coiling simulation. CFD analyses were conducted with the flat neck surface and the curved neck surface. We estimated 6 morphological parameters and 35 hemodynamic parameters, and the mean values of hemodynamic parameters were compared between the flat neck surface and the curved neck surface. The change rate of each parameter in the curved neck was calculated based on that in the flat neck. Since the velocity and pressure were involved in recanalization factors by the previous studies, as illustrative hemodynamic parameters, the mean values and change rate of the spatially averaged velocity normal to the neck surface into the cerebral aneurysm (NVneck) and the pressure difference between the average pressure on the surface of control volume and the maximum pressure at the neck surface (PDneck) were summarized in Table 1. These parameters were higher with the curved neck surface geometry case than with the flat neck surface geometry case. Furthermore, the change rates were higher in the recanalized cases compared to those in the stable cases. In the CFD analysis with the curved surface, the averaged inflow velocity and pressure difference at the neck surface were higher than those with the flat surface. In addition, the change rates of hemodynamic parameters in recanalized cases were higher than those of stable cases. Therefore, the hemodynamic parameters are changed depending on the geometry of the neck surface, which may affect the prediction accuracy for recanalization using CFD.
{"title":"Abstract Number ‐ 58: Effects of Neck Geometry on Reccurence in CFD Analysis for Aneurysms after Low VER Coiling","authors":"Hayato Uchikawa, H. Takao, S. Fujimura, Tomoki Kasai, Shota Sunami, Kazuya Yuzawa, T. Ishibashi, K. Fukudome, M. Yamamoto, Y. Murayama","doi":"10.1161/svin.03.suppl_1.058","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.058","url":null,"abstract":"\u0000 \u0000 Although low volume embolization ratio is known as risk factor of aneurysmal recanalization, stable occlusion can be achieved in limited cases. Evaluation of hemodynamic parameters at the neck surface has usually been performed with a flat surface rather than a curved surface following the actual coil shape. In this study, we investigated the effect of the geometry of the neck surface on hemodynamics related to aneurysm recanalization after coil embolization in low volume embolization ratio.\u0000 \u0000 \u0000 \u0000 We focused on aneurysms of 5–10 mm in size that were conducted coil embolization with 15–20% volume embolization ratio (low‐VER). Aneurysms that were recanalized after coil embolization and conducted additional coil deployment were defined as the recanalized case. We identified 25 aneurysms (7 recanalized and 18 stable). We randomly selected 3 recanalized cases and 6 stable cases. For each case, the three‐dimensional vascular geometry including aneurysm was reconstructed by preoperative angiographic images. To divide the aneurysm from the parent artery, two types of neck surfaces (flat neck surface and curved neck surface) were generated for each case. The embolized coil was modeled in the enclosed area with the neck plane and aneurysmal wall by our original virtual coiling simulation. CFD analyses were conducted with the flat neck surface and the curved neck surface. We estimated 6 morphological parameters and 35 hemodynamic parameters, and the mean values of hemodynamic parameters were compared between the flat neck surface and the curved neck surface. The change rate of each parameter in the curved neck was calculated based on that in the flat neck.\u0000 \u0000 \u0000 \u0000 Since the velocity and pressure were involved in recanalization factors by the previous studies, as illustrative hemodynamic parameters, the mean values and change rate of the spatially averaged velocity normal to the neck surface into the cerebral aneurysm (NVneck) and the pressure difference between the average pressure on the surface of control volume and the maximum pressure at the neck surface (PDneck) were summarized in Table 1. These parameters were higher with the curved neck surface geometry case than with the flat neck surface geometry case. Furthermore, the change rates were higher in the recanalized cases compared to those in the stable cases.\u0000 \u0000 \u0000 \u0000 In the CFD analysis with the curved surface, the averaged inflow velocity and pressure difference at the neck surface were higher than those with the flat surface. In addition, the change rates of hemodynamic parameters in recanalized cases were higher than those of stable cases. Therefore, the hemodynamic parameters are changed depending on the geometry of the neck surface, which may affect the prediction accuracy for recanalization using CFD.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48893919","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.134
B. Pabón, V. Torres, M. Patiňo, J. Peláez, J. Mútis, M. Cardozo
Few years after introduction, Flow disruption technology using WEB device has been used safely for the treatment of wide‐neck bifurcation aneurysms, but the use of this endosaccular approach to treat side‐wall lesions in terms of feasibility, safety, stability and aneurysm occlusion rate after this treatment is unknown. Patients were carefully selected. IRB approved. Clinical, anatomical, angiographical and technical considerations were analyzed. Procedure related complications, procedural time, antiplatelet therapy requirements. Web Occlusion Scale (WOS) was used for the Follow‐up. From August 2017 and March 2021 a total of 14 wide‐necked, sidewall, IA were selected for WEB treatment. Aneurysm mean size 5.3mm in width and 5.8 in height. Aneurysm Location: ICA 8 cases (five PComA, two Carotid‐ophtalmic segment, one AChoA segment), Superior Cerebellar Artery SCA in 5 patients (35%), and one impressive case in posterior circulation associated with a basilar fenestration next to VBJ. Eight cases were unruptured (57%), and six cases with history of SAH‐ acute setting. DAPT used pre operatively in all elective cases but none patient remain under antiplatelets after procedure. Technical success of 100%. Mean procedure time: 24 min. None related procedure complications recorded. Immediately angiographic occlusion was evidenced in 9 cases. Radiological Follow up (ranging 1‐ 26 months) available in 9/14 showed a WOS adequate occlusion in all cases. In our early experience using WEB device to treat different conditions than bifurcation IA´s, the results showed that endossacular approach was feasible in highly selected patients, safety profile in agreement with previous bifurcation experiences and very effective to treat challenge cases with a high probability of recurrence or therapeutic failure. Larger series and controlled studies are required to expand its indications in a near future.
{"title":"Abstract Number ‐ 134: How far can we go? WEB technology for the treatment of sidewall IA. Single Institution.","authors":"B. Pabón, V. Torres, M. Patiňo, J. Peláez, J. Mútis, M. Cardozo","doi":"10.1161/svin.03.suppl_1.134","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.134","url":null,"abstract":"\u0000 \u0000 Few years after introduction, Flow disruption technology using WEB device has been used safely for the treatment of wide‐neck bifurcation aneurysms, but the use of this endosaccular approach to treat side‐wall lesions in terms of feasibility, safety, stability and aneurysm occlusion rate after this treatment is unknown.\u0000 \u0000 \u0000 \u0000 Patients were carefully selected. IRB approved. Clinical, anatomical, angiographical and technical considerations were analyzed. Procedure related complications, procedural time, antiplatelet therapy requirements. Web Occlusion Scale (WOS) was used for the Follow‐up.\u0000 \u0000 \u0000 \u0000 From August 2017 and March 2021 a total of 14 wide‐necked, sidewall, IA were selected for WEB treatment. Aneurysm mean size 5.3mm in width and 5.8 in height. Aneurysm Location: ICA 8 cases (five PComA, two Carotid‐ophtalmic segment, one AChoA segment), Superior Cerebellar Artery SCA in 5 patients (35%), and one impressive case in posterior circulation associated with a basilar fenestration next to VBJ. Eight cases were unruptured (57%), and six cases with history of SAH‐ acute setting. DAPT used pre operatively in all elective cases but none patient remain under antiplatelets after procedure. Technical success of 100%. Mean procedure time: 24 min. None related procedure complications recorded. Immediately angiographic occlusion was evidenced in 9 cases. Radiological Follow up (ranging 1‐ 26 months) available in 9/14 showed a WOS adequate occlusion in all cases.\u0000 \u0000 \u0000 \u0000 In our early experience using WEB device to treat different conditions than bifurcation IA´s, the results showed that endossacular approach was feasible in highly selected patients, safety profile in agreement with previous bifurcation experiences and very effective to treat challenge cases with a high probability of recurrence or therapeutic failure. Larger series and controlled studies are required to expand its indications in a near future.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48967676","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.084
Priya Nidamanuri, R. Nogueira, Kunal Malik, A. M. Ruiz, M. McDowell, A. Al-Bayati
Intracranial pseudoaneurysms are rare lesions that represent less than 1% of all intracranial aneurysms.1They typically occur due to disruption of the arterial wall layers and subsequent extramural/extraluminal hematoma formation following traumatic brain injury, resulting in a higher risk of rebleeding than that of saccular cerebral aneurysms.2Pseudoaneurysms have higher incidence in children and young adults, and given their association with high morbidity and mortality, early detection and management is essential.2‐4The purpose of this study is to highlight the importance of early recognition and management of traumatic pseudoaneurysms prior to decompressive hemicraniectomy. This is a case report of a six‐year‐old previously healthy male who presented as a level 1 trauma alert after sustaining a gunshot wound to the face while manipulating an unsecured weapon at his residence. Upon arrival, lack of airway protection requiring intubation, entry wound to the anterior forehead, and diffuse forehead and periorbital edema were observed. CT head demonstrated multicompartmental hemorrhage with 6mm right to left midline shift and diffuse cerebral edema. CTA head and neck noted possible thrombosed right anterior cerebral artery (ACA) pseudoaneurysm in the right frontoparietal region (Figure 1‐A). Prior to decompressive hemicraniectomy, neuro‐endovascular consultation was obtained, and emergent cerebral angiogram was recommended. This case highlights the findings demonstrated on cerebral angiography, the technique by which the pseudoaneurysm was detected and secured, and the importance of doing so prior to further neurosurgical interventions. The patient was taken for diagnostic cerebral angiogram via femoral artery access. Initial angiographic run of the right internal carotid artery demonstrated distal right pericallosal artery slowing without clear evidence of underlying vascular injuries. Given concern for underlying thrombosed pseudoaneurysm and its parent branch, selective catheterization of the proximal pericallosal artery off the distal ACA was performed. Gentle angiographic run was obtained via microcatheter that demonstrated superior parietal artery pseudoaneurysm without active extravasation (Figure 1‐B). The microcatheter was advanced and placed in the proximal portion of the pseudoaneurysm sac and five platinum coils were deployed to fully obliterate the pseudoaneurysm and its parent feeder while protecting the adjacent paracentral artery (Figure 1‐C, 1‐D). Following completion of the endovascular procedure, the patient was transferred to the operative room for right decompressive hemicraniectomy and clot evacuation, which were completed successfully. Prompt detection and securement of traumatic intracranial pseudoaneurysms are essential prior to invasive neurosurgical interventions to reduce risk of recurrent bleeding. Selective angiographic evaluation of the parent injured vessel(s) is crucial for optimal assessme
{"title":"Abstract Number ‐ 84: Importance of Early Detection and Treatment of Traumatic Intracranial Pseudoaneurysms Prior to Decompressive Hemicraniectomy","authors":"Priya Nidamanuri, R. Nogueira, Kunal Malik, A. M. Ruiz, M. McDowell, A. Al-Bayati","doi":"10.1161/svin.03.suppl_1.084","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.084","url":null,"abstract":"\u0000 \u0000 Intracranial pseudoaneurysms are rare lesions that represent less than 1% of all intracranial aneurysms.1They typically occur due to disruption of the arterial wall layers and subsequent extramural/extraluminal hematoma formation following traumatic brain injury, resulting in a higher risk of rebleeding than that of saccular cerebral aneurysms.2Pseudoaneurysms have higher incidence in children and young adults, and given their association with high morbidity and mortality, early detection and management is essential.2‐4The purpose of this study is to highlight the importance of early recognition and management of traumatic pseudoaneurysms prior to decompressive hemicraniectomy.\u0000 \u0000 \u0000 \u0000 This is a case report of a six‐year‐old previously healthy male who presented as a level 1 trauma alert after sustaining a gunshot wound to the face while manipulating an unsecured weapon at his residence. Upon arrival, lack of airway protection requiring intubation, entry wound to the anterior forehead, and diffuse forehead and periorbital edema were observed. CT head demonstrated multicompartmental hemorrhage with 6mm right to left midline shift and diffuse cerebral edema. CTA head and neck noted possible thrombosed right anterior cerebral artery (ACA) pseudoaneurysm in the right frontoparietal region (Figure 1‐A). Prior to decompressive hemicraniectomy, neuro‐endovascular consultation was obtained, and emergent cerebral angiogram was recommended. This case highlights the findings demonstrated on cerebral angiography, the technique by which the pseudoaneurysm was detected and secured, and the importance of doing so prior to further neurosurgical interventions.\u0000 \u0000 \u0000 \u0000 The patient was taken for diagnostic cerebral angiogram via femoral artery access. Initial angiographic run of the right internal carotid artery demonstrated distal right pericallosal artery slowing without clear evidence of underlying vascular injuries. Given concern for underlying thrombosed pseudoaneurysm and its parent branch, selective catheterization of the proximal pericallosal artery off the distal ACA was performed. Gentle angiographic run was obtained via microcatheter that demonstrated superior parietal artery pseudoaneurysm without active extravasation (Figure 1‐B). The microcatheter was advanced and placed in the proximal portion of the pseudoaneurysm sac and five platinum coils were deployed to fully obliterate the pseudoaneurysm and its parent feeder while protecting the adjacent paracentral artery (Figure 1‐C, 1‐D). Following completion of the endovascular procedure, the patient was transferred to the operative room for right decompressive hemicraniectomy and clot evacuation, which were completed successfully.\u0000 \u0000 \u0000 \u0000 Prompt detection and securement of traumatic intracranial pseudoaneurysms are essential prior to invasive neurosurgical interventions to reduce risk of recurrent bleeding. Selective angiographic evaluation of the parent injured vessel(s) is crucial for optimal assessme","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49142529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.lba1
P. Dhillon, Waleed Z. Butt, T. Jovin, A. Podlasek, N. McConachie, R. Lenthall, S. Nair, Luqman Malik, K. Krishnan, Iacopo Chiavacci, F. Mehedi, Timothy Hong, Harriwin Selva, R. Dineen, T. England
The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from acute ischaemic stroke (AIS) onset for patients with proximal large vessel occlusion (LVO) selected without CT perfusion or MR imaging is undetermined in routine clinical practice. In this single centre study, we identified consecutive AIS patients with an ICA or M1 MCA segment occlusion who were eligible for EVT based on non‐contrast CT/CT angiography (without CT perfusion or MR imaging) using an Alberta Stroke Program Early CT Score (ASPECTS) of ≥ 6, and an NIHSS score of≥ 6, presenting beyond 6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT‐eligible patients presenting out of regular working hours (between 18.00 and 08.00 on weekdays) or on weekends, consistently received best medical management (BMM). This systemic unavailability of EVT, allows a comparison of EVT and BMM in patients who meet the same inclusion criteria, in which selection based on physician‐related bias is significantly reduced. Functional outcomes (modified Rankin Scale (mRS) at 90 days), symptomatic intracranial haemorrhage (sICH) and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, ASPECTS, onset‐to‐neuroimaging time, IV thrombolysis, and clot location.Pre‐specified subgroup analyses were performed. Among 4802 AIS patients, 150 patients (3.1%) presenting beyond 6‐hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared to the BMM group, patients treated with EVT had significantly improved functional outcome (mRS) (adjusted common OR = 2.23, 95%CI 1.18‐4.22, p = 0.013), and higher rates of functional independence (mRS≤2; 39.2.% vs 9.2%; aOR = 4.73, 95%CI 1.64‐13.63, p = 0.004). No significant difference was observed between the EVT and BMM groups in the sICH (5.4% vs 2.6%, p = 0.94) or mortality (20.2% vs 47.3%, p = 0.16) rates, respectively. EVT remained effective within the 6–12 hour and >12 hour time window subgroups. No significant treatment interaction was observed in all subgroups. In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by NCCT/CTA alone, those treated with EVT achieved significantly improved functional outcome, compared to patients treated with BMM only. No significant differences were noted between the two groups with respect to sICH and mortality. While confirmatory randomised trials are awaited, these findings suggest that EVT is effective and safe when performed in AIS patients selected without CTP or MRI beyond 6 hours from stroke onset.
在常规临床实践中，对于没有CT灌注或MR成像的近端大血管闭塞(LVO)患者，在急性缺血性卒中(AIS)发病后6小时内血管内取栓(EVT)的有效性和安全性尚不确定。在这项单中心研究中，我们确定了具有ICA或M1 MCA段闭塞的连续AIS患者，这些患者符合EVT的条件，基于非对比CT/CT血管造影(无CT灌注或MR成像)，使用阿尔伯塔卒中计划早期CT评分(ASPECTS)≥6,NIHSS评分≥6，在2018年1月至2022年3月期间卒中发作超过6小时。在研究期间，EVT容量限制意味着EVT符合条件的患者在正常工作时间(工作日18:00至08:00之间)或周末就诊，始终接受最佳医疗管理(BMM)。由于EVT的全体性缺失，可以对符合相同纳入标准的患者进行EVT和BMM的比较，其中基于医生相关偏倚的选择显着减少。在年龄、性别、基线卒中严重程度、各方面因素、发病至神经成像时间、静脉溶栓和血栓位置等多变量调整后，比较EVT或BMM患者90天的功能结局(改良Rankin量表(mRS))、症状性颅内出血(sICH)和死亡率。进行预先指定的亚组分析。在4802名AIS患者中，150名发病时间超过6小时的患者(3.1%)符合EVT治疗条件:74名(49%)接受EVT治疗，76名(51%)接受BMM治疗。与BMM组相比，EVT治疗的患者功能预后(mRS)显著改善(调整后常见OR = 2.23, 95%CI 1.18‐4.22,p = 0.013)，功能独立性率更高(mRS≤2;39.2.% vs 9.2%;aOR = 4.73, 95%CI 1.64‐13.63,p = 0.004)。EVT组和BMM组在siich发生率(5.4% vs 2.6%， p = 0.94)和死亡率(20.2% vs 47.3%， p = 0.16)方面均无显著差异。EVT在6-12小时和10 - 12小时时间窗口亚组内仍然有效。在所有亚组中均未观察到显著的治疗相互作用。在常规临床实践中，在卒中发作6小时后出现的3.1%的AIS患者中，仅通过NCCT/CTA被认为符合EVT治疗条件，与仅接受BMM治疗的患者相比，接受EVT治疗的患者功能预后显著改善。在sICH和死亡率方面，两组之间没有显著差异。虽然还有待验证性随机试验，但这些研究结果表明，在卒中发作后6小时内选择无CTP或MRI的AIS患者进行EVT是有效和安全的。
{"title":"Abstract Number: LBA1 Endovascular Thrombectomy vs Best Medical Therapy for Late Presentation Ischaemic Stroke Selected using Non‐Contrast CT","authors":"P. Dhillon, Waleed Z. Butt, T. Jovin, A. Podlasek, N. McConachie, R. Lenthall, S. Nair, Luqman Malik, K. Krishnan, Iacopo Chiavacci, F. Mehedi, Timothy Hong, Harriwin Selva, R. Dineen, T. England","doi":"10.1161/svin.03.suppl_1.lba1","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.lba1","url":null,"abstract":"\u0000 \u0000 The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from acute ischaemic stroke (AIS) onset for patients with proximal large vessel occlusion (LVO) selected without CT perfusion or MR imaging is undetermined in routine clinical practice.\u0000 \u0000 \u0000 \u0000 In this single centre study, we identified consecutive AIS patients with an ICA or M1 MCA segment occlusion who were eligible for EVT based on non‐contrast CT/CT angiography (without CT perfusion or MR imaging) using an Alberta Stroke Program Early CT Score (ASPECTS) of ≥ 6, and an NIHSS score of≥ 6, presenting beyond 6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT‐eligible patients presenting out of regular working hours (between 18.00 and 08.00 on weekdays) or on weekends, consistently received best medical management (BMM). This systemic unavailability of EVT, allows a comparison of EVT and BMM in patients who meet the same inclusion criteria, in which selection based on physician‐related bias is significantly reduced. Functional outcomes (modified Rankin Scale (mRS) at 90 days), symptomatic intracranial haemorrhage (sICH) and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, ASPECTS, onset‐to‐neuroimaging time, IV thrombolysis, and clot location.Pre‐specified subgroup analyses were performed.\u0000 \u0000 \u0000 \u0000 Among 4802 AIS patients, 150 patients (3.1%) presenting beyond 6‐hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared to the BMM group, patients treated with EVT had significantly improved functional outcome (mRS) (adjusted common OR = 2.23, 95%CI 1.18‐4.22, p = 0.013), and higher rates of functional independence (mRS≤2; 39.2.% vs 9.2%; aOR = 4.73, 95%CI 1.64‐13.63, p = 0.004). No significant difference was observed between the EVT and BMM groups in the sICH (5.4% vs 2.6%, p = 0.94) or mortality (20.2% vs 47.3%, p = 0.16) rates, respectively. EVT remained effective within the 6–12 hour and >12 hour time window subgroups. No significant treatment interaction was observed in all subgroups.\u0000 \u0000 \u0000 \u0000 In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by NCCT/CTA alone, those treated with EVT achieved significantly improved functional outcome, compared to patients treated with BMM only. No significant differences were noted between the two groups with respect to sICH and mortality. While confirmatory randomised trials are awaited, these findings suggest that EVT is effective and safe when performed in AIS patients selected without CTP or MRI beyond 6 hours from stroke onset.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43239706","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.079
S. Capone, B. Patel
Arterial pseudoaneurysms and arteriovenous fistulas of intracranial and extracranial vessels are an uncommon occurrence following blunt and penetrating trauma and are commonly treated by vessel sacrifice,dependent on collateral flow1‐3. Others have treated these cases with covered stents4 and flow diversion5. Advances in flow diversion technology have led to their use in other pathologies, including carotid cavernous fistulas6 and vertebral artery pseudoaneurysms7. We present a case of a traumatic arteriovenous fistula of the dominant vertebral artery requiring vessel preservation and reconstruction. A 42‐year‐old male presented with a gunshot wound to the face below the right eye. Trauma imaging identified fractures of the right maxillary sinus and orbital floor. CTA of the head/neck showed a dominant right vertebral artery dissection and pseudoaneurysm with a non‐dominant left vertebral artery (VA), effectively ending in PICA. Due to the inefficient supply to the posterior circulation via the left VA, the decision was made to preserve and reconstruct the right VA and the patient was brought to the angiography suite. Angiographically, the patient was noted to have retrograde filling of the posterior circulation, basilar and right VA through the anterior circulation in injection of both ICAs, suggesting decreased antegrade flow from the injured right VA. The right VA was catheterized which showed a high‐flow, high‐grade arteriovenous fistula from the V3 segment with venous drainage into multiple extraspinal cervical and epidural cervical veins. This also identified the fistulous point at the location of the pseudoaneurysm on CTA. The diagnostic catheter was exchanged for a guide catheter, and a Phenom 27 microcatheter (Medtronic; Minneapolis, MN) was navigated into the basilar artery. A Duo microcatheter (Microvention; Aliso Viejo, CA)/Synchro 2 (Stryker; Kalamazoo, MI) standard microwire complex was used to identify the fistulous point and positioned for jailing. A Pipeline Flex 4.75×20mm (Medtronic; Minneapolis, MN) was deployed from the proximal V4 segment across the pseudoaneurysm with persistence of the AVF. A second Pipeline Flex 5×20mm was placed in telescoping fashion with persistence of the AVF. A third Pipeline Flex 5×16mm was placed in telescoping fashion and flow diversion was observed. Using the jailed catheter, the pseudoaneurysm and fistulous point were coil embolized using a combination of helical and 3D HydroSoft coils (Microvention; Aliso Viejo, CA) of varying sizes. Final angiogram demonstrated resolution of the high‐flow AVF, improvement of antegrade flow through the right vertebral artery, and a slow‐flow low‐grade fistulous communication with the posterior extraspinal cervical veins. There were no thromboembolic complications and the patient recovered well from the procedure. Follow‐up angiography at 2 months post‐treatment showed obliteration of the AVF with a small remnant pseudoaneurysm of the right V3 s
{"title":"Abstract Number ‐ 79: Flow Diversion for Traumatic Vertebral Artery Arteriovenous Fistula: A Case Report","authors":"S. Capone, B. Patel","doi":"10.1161/svin.03.suppl_1.079","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.079","url":null,"abstract":"\u0000 \u0000 Arterial pseudoaneurysms and arteriovenous fistulas of intracranial and extracranial vessels are an uncommon occurrence following blunt and penetrating trauma and are commonly treated by vessel sacrifice,dependent on collateral flow1‐3. Others have treated these cases with covered stents4 and flow diversion5. Advances in flow diversion technology have led to their use in other pathologies, including carotid cavernous fistulas6 and vertebral artery pseudoaneurysms7. We present a case of a traumatic arteriovenous fistula of the dominant vertebral artery requiring vessel preservation and reconstruction.\u0000 \u0000 \u0000 \u0000 A 42‐year‐old male presented with a gunshot wound to the face below the right eye. Trauma imaging identified fractures of the right maxillary sinus and orbital floor. CTA of the head/neck showed a dominant right vertebral artery dissection and pseudoaneurysm with a non‐dominant left vertebral artery (VA), effectively ending in PICA.\u0000 \u0000 \u0000 \u0000 Due to the inefficient supply to the posterior circulation via the left VA, the decision was made to preserve and reconstruct the right VA and the patient was brought to the angiography suite. Angiographically, the patient was noted to have retrograde filling of the posterior circulation, basilar and right VA through the anterior circulation in injection of both ICAs, suggesting decreased antegrade flow from the injured right VA. The right VA was catheterized which showed a high‐flow, high‐grade arteriovenous fistula from the V3 segment with venous drainage into multiple extraspinal cervical and epidural cervical veins. This also identified the fistulous point at the location of the pseudoaneurysm on CTA. The diagnostic catheter was exchanged for a guide catheter, and a Phenom 27 microcatheter (Medtronic; Minneapolis, MN) was navigated into the basilar artery. A Duo microcatheter (Microvention; Aliso Viejo, CA)/Synchro 2 (Stryker; Kalamazoo, MI) standard microwire complex was used to identify the fistulous point and positioned for jailing. A Pipeline Flex 4.75×20mm (Medtronic; Minneapolis, MN) was deployed from the proximal V4 segment across the pseudoaneurysm with persistence of the AVF. A second Pipeline Flex 5×20mm was placed in telescoping fashion with persistence of the AVF. A third Pipeline Flex 5×16mm was placed in telescoping fashion and flow diversion was observed. Using the jailed catheter, the pseudoaneurysm and fistulous point were coil embolized using a combination of helical and 3D HydroSoft coils (Microvention; Aliso Viejo, CA) of varying sizes. Final angiogram demonstrated resolution of the high‐flow AVF, improvement of antegrade flow through the right vertebral artery, and a slow‐flow low‐grade fistulous communication with the posterior extraspinal cervical veins. There were no thromboembolic complications and the patient recovered well from the procedure. Follow‐up angiography at 2 months post‐treatment showed obliteration of the AVF with a small remnant pseudoaneurysm of the right V3 s","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46341039","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.111
R. Morsi, S. Thind, Archit B. Baskaran, J. Carrión-Penagos, C. Kramer, C. Lazaridis, F. Goldenberg, S. Prabhakaran, A. Mansour, T. Kass-Hout
There is limited evidence on the use of N‐butyl cyanoacrylate (n‐BCA) liquid embolic in endovascular embolization of traumatic face and neck vessel injuries. We sought to investigate the safety and effectiveness of n‐BCA in treating traumatic vessel injuries. In a prospectively maintained database, we retrospectively analyzed consecutive patients who presented with a vessel injury caused by either a penetrating or blunt injury in a large academic Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years with any vessel injury in the face and neck circulation. The primary endpoint was effectiveness of n‐BCA by immediate control of the active bleeding post‐embolization. A total of 10 patients required neuro‐endovascular embolization of traumatic vessel injury via n‐BCA. The mean age of patients was 41.10 (95%CI 28.41, 53.79), with a male predominance (n = 8, 80.0%). The mean Glasgow Coma Scale score on presentation was 10 (95% CI 6.20, 14.40). One patient had concomitant brain injury having subdural and subarachnoid hemorrhages. The mean score for Biffl classification was 5.00. Eight patients suffered penetrating gunshot wound injuries, and two patients suffered blunt injuries. Injured vessels included facial artery (n = 4, 40.0%), buccal branch artery (n = 2, 20.0%), internal maxillary artery (n = 2, 20.0%), cervical segment of the internal carotid artery (n = 1, 10.0%), and the V2 segment of the vertebral artery (n = 1, 10.0%). All patients were successfully treated with 2:1 n‐BCA to ethiodol with immediate extravasation control. Balloon guide catheter was used in 3 patients (30.0%). There was no recurrence of bleeding via vessel imaging or need for retreatment. One patient died in‐hospital (10.0%). Most patients were discharged home (n = 5, 50.0%), one discharged home with day rehab (n = 1, 10.0%), and one to an acute rehab facility (n = 1, 10.0%). One patient developed a right posterior cerebral artery territory infarct with hemorrhagic transformation post‐embolization. To the best of our knowledge, this is the first study demonstrating the safety and effectiveness of n‐BCA liquid embolic in traumatic vessel injuries, especially penetrating gunshot wound injuries. Further research is needed to investigate the safety and efficacy in this population.
{"title":"Abstract Number ‐ 111: Endovascular embolization of traumatic vessel injury using n‐butyl cyanoacrylate: A case series","authors":"R. Morsi, S. Thind, Archit B. Baskaran, J. Carrión-Penagos, C. Kramer, C. Lazaridis, F. Goldenberg, S. Prabhakaran, A. Mansour, T. Kass-Hout","doi":"10.1161/svin.03.suppl_1.111","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.111","url":null,"abstract":"\u0000 \u0000 There is limited evidence on the use of N‐butyl cyanoacrylate (n‐BCA) liquid embolic in endovascular embolization of traumatic face and neck vessel injuries. We sought to investigate the safety and effectiveness of n‐BCA in treating traumatic vessel injuries.\u0000 \u0000 \u0000 \u0000 In a prospectively maintained database, we retrospectively analyzed consecutive patients who presented with a vessel injury caused by either a penetrating or blunt injury in a large academic Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years with any vessel injury in the face and neck circulation. The primary endpoint was effectiveness of n‐BCA by immediate control of the active bleeding post‐embolization.\u0000 \u0000 \u0000 \u0000 A total of 10 patients required neuro‐endovascular embolization of traumatic vessel injury via n‐BCA. The mean age of patients was 41.10 (95%CI 28.41, 53.79), with a male predominance (n = 8, 80.0%). The mean Glasgow Coma Scale score on presentation was 10 (95% CI 6.20, 14.40). One patient had concomitant brain injury having subdural and subarachnoid hemorrhages. The mean score for Biffl classification was 5.00. Eight patients suffered penetrating gunshot wound injuries, and two patients suffered blunt injuries. Injured vessels included facial artery (n = 4, 40.0%), buccal branch artery (n = 2, 20.0%), internal maxillary artery (n = 2, 20.0%), cervical segment of the internal carotid artery (n = 1, 10.0%), and the V2 segment of the vertebral artery (n = 1, 10.0%). All patients were successfully treated with 2:1 n‐BCA to ethiodol with immediate extravasation control. Balloon guide catheter was used in 3 patients (30.0%). There was no recurrence of bleeding via vessel imaging or need for retreatment. One patient died in‐hospital (10.0%). Most patients were discharged home (n = 5, 50.0%), one discharged home with day rehab (n = 1, 10.0%), and one to an acute rehab facility (n = 1, 10.0%). One patient developed a right posterior cerebral artery territory infarct with hemorrhagic transformation post‐embolization.\u0000 \u0000 \u0000 \u0000 To the best of our knowledge, this is the first study demonstrating the safety and effectiveness of n‐BCA liquid embolic in traumatic vessel injuries, especially penetrating gunshot wound injuries. Further research is needed to investigate the safety and efficacy in this population.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46407294","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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