RESUMEN
An abnormal connection between the carotid artery and cavernous sinus is referred to as a carotid cavernous fistula (CCF). A direct CCF results when the connection occurs between the intracranial internal carotid artery (ICA) and the cavernous sinus. These events are typically the result of a head injury, but can also be iatrogenic, resulting from various intracranial procedures. Direct CCF occurrences rarely heal spontaneously due to the high flow rate across the fistula. In this report, we present an uncommon case involving a delayed iatrogenic direct CCF, which developed following the placement of a pipeline flow-diverting stent that was used to treat a cerebral aneurysm. Interestingly, this unusual iatrogenic direct CCF subsequently spontaneously resolved within a few months. To our knowledge, this is the only case of a delayed CCF occurring with the use of a flow-diverting sent, which then resolved on its own. This report recounts our experience with the case.
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OBJECTIVE Intracranial atherosclerotic disease (ICAD) accounts for approximately 10% of ischemic strokes. The recent Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study demonstrated a high incidence of perioperative complications (15%) for treatment of ICAD with stenting. Although the incidence of stroke was lower in the medical arm, recurrent stroke was found in 12% of patients despite aggressive medical management, suggesting that intervention may remain a viable option for ICAD if perioperative risk is minimized. Angioplasty without stenting represents an alternative and understudied revascularization treatment for ICAD. Submaximal angioplasty limits the risks of thromboembolism, vessel perforation, and reperfusion hemorrhage that were frequently reported with stenting in the SAMMPRIS trial. The authors conducted a prospective Phase I trial designed to assess the safety of submaximal angioplasty in patients with symptomatic ICAD. METHODS This study was approved by the local institutional review board. Demographic and clinical data were prospectively collected. Angioplasty was performed with a balloon undersized to approximately 50%-70% of the nondiseased vessel diameter in patients with symptomatic ICAD who had angiographically significant stenosis of ≥ 70%. The primary outcome measure was the incidence of periprocedural complications (combined rate of death, stroke, and hemorrhage occurring within 30 days and at 1 year). RESULTS Among the 65 patients with symptomatic ICAD who were screened, 24 had significant angiographic stenosis that met the inclusion criteria of this study. The mean age was 64.08 years (median 65 years; SD ± 11.24 years), most were men (62.5%), and most were white (66.67%). Many patients had concomitants of vascular disease, including hypertension (95.8%), hyperlipidemia (70.83%), smoking history (54.1%), and diabetes mellitus (50.0%). Coronary artery disease (41.66%) and previous stroke or transient ischemic attack (45.83%) were frequently present. Most patients (75%) had anterior circulation stenosis. The mean preprocedure stenosis was 80.16% (median 80%, range 70%-95%). Submaximal angioplasty was performed in patients who met the inclusion criteria, with a mean postangioplasty stenosis rate of 54.62% (median 55.5%, range 31%-78%). Rates of ischemic stroke in the territory of the treated artery were 0% within 30 days and 5.55% (in the only patient who presented with recurrent stroke) at 1 year. The mortality and hemorrhage rates in this series were 0%. CONCLUSIONS This study demonstrates the safety of the submaximal angioplasty technique, with no permanent periprocedural complications in 24 treated patients.
Asunto(s)
Angioplastia/métodos , Arteriosclerosis Intracraneal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Arteriosclerosis Intracraneal/diagnóstico , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
UNLABELLED: A 57-year-old woman with National Institutes of Health Stroke Scale (NIHSS) score of 26 was found to have an acute left carotid occlusion with tandem left M1 thrombus within 1.5 hours of symptom onset. After no neurologic improvement following standard-dose intravenous (IV) recombinant tissue plasminogen activator (rtPA), emergent neuroendovascular revascularization with carotid stenting and intracranial thrombectomy were performed under conscious sedation. Thrombolysis in myocardial infarction (TIMI)-3 flow restoration and symptom resolution were achieved postprocedure; however, complete carotid stent thrombosis was noted on final angiographic runs (25 minutes later), correlating with neurologic decline. Rapid administration of an intraarterial (IA) bolus dose of eptifibatide resulted in TIMI-3 flow restoration, with neurologic improvement. The patient was discharged three days postrevascularization on dual antiplatelet therapy with an NIHSS score of 1. Intraarterial (IA) eptifibatide can be an effective option for acute stent occlusion during emergent neuroendovascular revascularization after IV rtPA administration. ABBREVIATIONS: CLEARCombined approach to lysis utilizing eptifibatide and RtPACTcomputed tomographicFrFrenchGPglycoproteinIAintraarterialICAinternal carotid arteryIVintravenousMCAmiddle cerebral arteryNIHSSNational Institutes of Health Stroke ScalertPArecombinant tissue plasminogen activatorTIMIthrombolysis in myocardial infarction.
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Carotid artery angioplasty and stenting (CAS) has experienced an astonishing rate of development over the last 2 decades, becoming a viable alternative to carotid endarterectomy (CEA) in the management of carotid stenosis. Many trials have attempted to compare both treatment modalities and establish indications for each, depending on clinical and anatomic features. In this article, the authors review the historical evolution of carotid stenting; its main technical aspects, indications, and contraindications; as well as the most important clinical trials comparing CAS and CEA.
Asunto(s)
Angioplastia de Balón , Estenosis Carotídea/terapia , Accidente Cerebrovascular/prevención & control , Estenosis Carotídea/diagnóstico , Procedimientos Endovasculares , Humanos , Stents , Resultado del TratamientoRESUMEN
BACKGROUND: Transsphenoidal tumor resection can lead to internal carotid artery (ICA) injury. Vascular disruption is often treated with emergent vessel deconstruction, incurring complications in a subset of patients with poor collateral circulation and resulting in minor and major ischemic strokes. METHODS: We attempted a novel approach combining a covered stent graft (Jostent) and two flow diverter stents [Pipeline embolization devices (PEDs)] to treat active extravasation from a disrupted right ICA that was the result of a transsphenoidal surgery complication. This disruption occurred during clival tumor surgery and required immediate sphenoidal sinus packing. Emergent angiography revealed continued petrous carotid artery extravasation, warranting emergent vessel repair or deconstruction for treatment. To preserve the vessel, we utilized a covered Jostent. Due to tortuosity and lack of optimal wall apposition, there was reduced, yet persistent extravasation from an endoleak after Jostent deployment that failed to resolve despite multiple angioplasties. Therefore, we used PEDs to divert the flow. RESULTS: Flow diversion relieved the extravasation. The patient remained neurologically intact post-procedure. CONCLUSIONS: This case demonstrates successful combined use of a covered stent and flow diverters to treat acute vascular injury resulting from transsphenoidal surgery. However, concerns remain, including the requirement of dual antiplatelet agents increasing postoperative bleeding risks, stent-related thromboembolic events, and delayed in-stent restenosis rates.
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BACKGROUND: Treatment of instent restenosis after carotid artery stenting because of circumferential or calcified lesions can be difficult and refractory to conventional balloon angioplasty. We describe the off-label use of a cardiac scoring balloon that was used for lesions refractory to angioplasty with other balloons. CASE DESCRIPTIONS: Two patients with a history of carotid artery stenting 6 and 8 years ago, presented with symptomatic carotid instent restenosis caused by circumferential and calcified lesions, respectively. Angioplasty with conventional compliant and noncompliant balloons was unsuccessful. An AngioSculpt percutaneous transluminal coronary angioplasty (PTCA) scoring balloon catheter (AngioScore, Fremont CA, USA) was successful in achieving vessel recanalization despite the refractory nature of these lesions. No further conventional balloons or use of cutting balloons was required. CONCLUSION: The AngioSculpt PTCA scoring balloon catheter can be a useful option for treatment of refractory calcified or circumferential carotid instent restenosis.
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Persistence of the hypoglossal artery into adulthood is a rare vascular anomaly and, when present, provides the predominant vascular supply to the posterior circulation. We describe a case of vertebrobasilar insufficiency associated with severe high-grade stenosis of the persistent hypoglossal artery and tandem stenosis of the proximal ipsilateral internal carotid artery, treated by an endovascular approach. The unique anatomical and technical challenges associated with this case are reviewed in detail.
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Estenosis Carotídea/cirugía , Procedimientos Endovasculares/métodos , Stents , Lengua/irrigación sanguínea , Anciano , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/diagnóstico por imagen , Procedimientos Endovasculares/instrumentación , Humanos , Angiografía por Resonancia Magnética , Tomografía Computarizada por Rayos XRESUMEN
Endovascular techniques are well suited for the treatment of posterior circulation aneurysms. This review describes the endovascular management of these aneurysms and discusses relevant technical advances.
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Procedimientos Endovasculares , Aneurisma Intracraneal/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/métodos , Humanos , Aneurisma Intracraneal/patologíaRESUMEN
Flow diversion is a new endovascular technique developed for treatment of intracranial aneurysms. It is based on stent-induced modification of blood flow within and around an aneurysm inflow zone, leading to gradual intra-aneurysmal thrombosis and subsequent atrophy, while preserving flow into the parent vessel and perforating branches. Flow-diversion technique is well-suited for the treatment of large, giant, wide-necked, and fusiform intracranial aneurysms because it does not rely on endosaccular packing with coils but rather on the strategy of placing a stent across the aneurysm "neck" or across the diseased segment of a vessel in case of a fusiform aneurysm. Over time, neointimal endothelium covers the flow diverter such that it becomes incorporated into the parent vessel wall and occludes the aneurysm from the circulation, effectively repairing the diseased parent vessel segment. This report describes in detail the Pipeline embolization device (ev3-Covidien, Irvine, California, USA), its mechanism of action and deployment technique, and reviews the pertinent literature regarding safety, efficacy and potential risks and complications associated with the use of this flow diverter.
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Embolización Terapéutica/instrumentación , Aneurisma Intracraneal/terapia , Animales , Análisis Costo-Beneficio , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/economía , Humanos , Aneurisma Intracraneal/economía , Complicaciones Posoperatorias/etiologíaRESUMEN
Recent advancements in all phases of endovascular aneurysm treatment, including medical therapy, diagnostics, devices, and implants, abound. Advancements in endovascular technologies and techniques have enabled treatment of a wide variety of intracranial aneurysms. In this article, technical advances in endovascular treatment of cerebral aneurysms are discussed, with an effort to incorporate a clinically relevant perspective. Advancements in diagnostic tools, medical therapy, and implants are reviewed and discussed.
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Embolización Terapéutica , Aneurisma Intracraneal/terapia , Procedimientos Neuroquirúrgicos , Embolización Terapéutica/métodos , Procedimientos Endovasculares , Humanos , Prótesis e ImplantesRESUMEN
Endovascular technique represents an important, minimally invasive approach to treating cerebrovascular disease. In this article, we discuss the origins of endovascular neurosurgery as a discipline in the context of important technical milestones, evidence-based medicine, and future cerebrovascular neurosurgical training. Cerebrovascular neurosurgery has seen a steady, convergent evolution toward the surgeon capable of seamless incorporation of open and endovascular approaches to any complex vascular disease affecting the central nervous system. Neurosurgery must assume the leadership role in the multidisciplinary neurovascular team.
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Trastornos Cerebrovasculares/cirugía , Procedimientos Endovasculares , Medicina Basada en la Evidencia/tendencias , Procedimientos Neuroquirúrgicos , Humanos , Procedimientos Neuroquirúrgicos/métodos , Resultado del TratamientoRESUMEN
Carotid artery stenting has become a viable alternative to carotid endarterectomy in the management of carotid stenosis. Over the past 20 years, many trials have attempted to compare both treatment modalities and establish the indications for each one, depending on clinical and anatomic features presented by patients. Concurrently, carotid stenting techniques and devices have evolved and made endovascular management of carotid stenosis safe and effective. Among the most important innovations are devices for distal and proximal embolic protection and new stent designs. This paper reviews these advances in the endovascular management of carotid artery stenosis within the context of the historical background.
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Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Angioplastia de Balón/métodos , Ensayos Clínicos como Asunto , Endarterectomía Carotidea/métodos , Humanos , Stents , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/cirugíaRESUMEN
OBJECTIVE: Limited data exist regarding the use of antiplatelet response assays during neuroendovascular intervention. We report outcomes after carotid artery stenting (CAS) based on aspirin and P2Y12 assays. METHODS: We retrospectively identified patients who had aspirin and P2Y12 assays at the time of stenting. Aspirin (325 mg) and clopidogrel (75 mg) were started 7-10 days pre-intervention. If not possible, aspirin (650 mg) and clopidogrel (600 mg) loading doses were given pre-intervention. Assays were checked on postoperative day 0/1. Outcomes included neurological ischemic sequela at 30 days, 1 and 2 years, as well as 30 day death/hemorrhage/myocardial infarction. RESULTS: 449 patients were included. Mean P2Y12 reaction unit (PRU) values were higher in patients with an ipsilateral ischemic event (stroke/transient ischemic attack (TIA)) or stroke (alone) at 1 and 2 years than in patients with no events: ischemic event versus no event at 1 year, 252 vs 202 (p=0.008); stroke versus no stroke at 1 year, 252 versus 203(p=0.029); ischemic event versus no event at 2 years, 244 vs 203 (p=0.047); stroke versus no stroke at 2 years, 243 versus 203 (p=0.082). Ischemic event free survival (stroke/TIA, p=0.0268) and overall survival (p=0.0291) post-CAS were longer in patients with PRU ≤198 compared with an initial threshold of PRU ≤237. Mean PRU values were higher in patients who died from all causes at 30 days than in survivors (p=0.031). No correlation was found between lower PRU values and hemorrhage. Aspirin reaction units did not correlate with outcome. CONCLUSIONS: PRU ≤198 may be associated with a lower incidence of ischemic neurological sequela and death post-CAS. Prospective studies are needed to validate the relationship between antiplatelet assays and outcomes post-CAS.
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Aspirina/administración & dosificación , Estenosis Carotídea/tratamiento farmacológico , Estenosis Carotídea/cirugía , Revascularización Cerebral/métodos , Stents , Ticlopidina/análogos & derivados , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/mortalidad , Isquemia Encefálica/prevención & control , Estenosis Carotídea/mortalidad , Clopidogrel , Monitoreo de Drogas/métodos , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Prevalencia , Receptores Purinérgicos P2Y12/metabolismo , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/prevención & control , Ticlopidina/administración & dosificación , Resultado del TratamientoRESUMEN
OBJECTIVE: Primary stenting for acute ischemic stroke (AIS) using the Wingspan stent delivery system has been reported. Major technical limitations in that study were difficulties in delivering the device and a few cases in which the Enterprise vascular reconstruction device (stent) was used as a bailout procedure. The Enterprise, which has relatively less radial force and more flexibility than other intracranial stents, is an ideal device for revascularization as it is easily delivered through tortuous intracranial vessels. We tested the safety and effectiveness of this stent as the primary revascularization device for AIS in an FDA-approved investigational device exemption prospective cohort study. METHODS: Twenty patients presenting with AIS due to confirmed intracranial large vessel occlusion within 8 h of onset of stroke symptoms were treated with the Enterprise as the primary revascularization device. The primary outcome was recanalization to Thrombolysis In Myocardial Infarction (TIMI) flow of ≥2. Perioperative safety was measured by major complication incidence within 30 days of stent revascularization. A secondary measure of outcome was 30-day modified Rankin Scale (mRS) score. RESULTS: Recanalization to TIMI 2 (n=6) or 3 (n=12) flow was achieved in 18 patients (90% revascularization rate). Three major complications were noted (15%) including one myocardial infarction, one symptomatic intracranial hemorrhage and one ischemic stroke in a distribution other than the qualifying vessel. Good outcome (mRS ≤2) was obtained in 10 patients (50%). CONCLUSIONS: In this prospective study the Enterprise stent was found to be a safe and effective revascularization tool in the setting of AIS.
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Prótesis Vascular , Isquemia Encefálica/cirugía , Revascularización Cerebral/instrumentación , Revascularización Cerebral/métodos , Stents , Accidente Cerebrovascular/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Angiografía Cerebral , Revascularización Cerebral/efectos adversos , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Proyectos Piloto , Accidente Cerebrovascular/diagnóstico por imagen , Trombectomía/efectos adversos , Trombectomía/instrumentación , Trombectomía/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Cerebral mycotic aneurysms are rare sequelae of systemic infections that can cause profound morbidity and mortality with rupture. Direct bacterial extension and vessel integrity compromise from septic emboli have been implicated as mechanisms for formation of these lesions. We report the 5-day development of a ruptured mycotic aneurysm arising from a septic embolism that caused a focal M1 pseudoocclusion. CASE DESCRIPTION: A 14-year-old girl developed acute left-sided hemiparesis while hospitalized for subacute bacterial endocarditis that was found after she presented with a 2-week history of fever, myalgia, shortness of breath, and lethargy. Mitral valve vegetations were confirmed in the setting of hemophilus bacteremia. Brain magnetic resonance (MR) imaging and angiography confirmed middle cerebral artery infarct with focal pseudoocclusion of the distal M1 segment. Given that further middle cerebral artery territory was at risk, a trial of heparin was attempted for revascularization but required discontinuation owing to hemorrhagic conversion. Decline of the patient's mental status necessitated craniectomy for decompression. Postoperatively, her mental status improved with residual left hemiparesis. On the third postoperative day (5 days after MR angiography), the patient's neurologic condition acutely declined, with development of right-sided mydriasis. Computed tomography (CT) angiography revealed a ruptured 19 × 16 mm pseudoaneurysm arising from the M1 site of the previous occlusion. Emergent coiling of aneurysm and parent vessel followed by hematoma evacuation ensued. At discharge, the patient had residual left hemiparesis but intact speech and cognition. CONCLUSION: Focal occlusions due to septic emboli should be considered high-risk for mycotic aneurysm formation, prompting aggressive monitoring with neuroimaging and treatment when indicated.
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Endovascular stroke therapy has revolutionized the management of patients with acute ischemic stroke in the last decade and has facilitated the development of sophisticated stroke imaging techniques and a multitude of thrombectomy devices. This article reviews the scientific basis and current evidence available to support endovascular revascularization and provides brief technical details of the various methods of endovascular thrombectomy with case examples.
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Revascularización Cerebral/métodos , Procedimientos Endovasculares/métodos , Trombolisis Mecánica/métodos , Accidente Cerebrovascular/terapia , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/administración & dosificación , Revascularización Cerebral/instrumentación , Terapia Combinada , Procedimientos Endovasculares/instrumentación , Fibrinolíticos/administración & dosificación , Humanos , Infusiones Intravenosas , Accidente Cerebrovascular/diagnósticoRESUMEN
Persistence of the hypoglossal artery into adulthood is a rare vascular anomaly and, when present, provides the predominant vascular supply to the posterior circulation. We describe a case of vertebrobasilar insufficiency associated with severe high-grade stenosis of the persistent hypoglossal artery and tandem stenosis of the proximal ipsilateral internal carotid artery, treated by an endovascular approach. The unique anatomical and technical challenges associated with this case are reviewed in detail.