Initial experience with angioplasty of symptomatic M2 MCA atheromatous lesions.

Background And Purpose: Symptomatic intracranial atherosclerosis has been associated with a high rate of recurrent stroke. The safety of treatment of more distal atheromatous lesions with angioplasty has not been systematically reported.

Methods: We retrospectively reviewed our institutional database for all patients treated with intracranial angioplasty and stenting from January 2008 to July 2009.

Comparison of techniques for stent assisted coil embolization of aneurysms.

Introduction: Stent assisted coiling (SAC) of aneurysms has been adopted with potential mechanical, hemodynamic and biologic properties imparting an advantage over coil embolization alone. The purpose of this investigation is to compare the various techniques of SAC at a single institution with regards to clinical, technical and angiographic complications and success.

Methods: Patients who underwent SAC between 2003 and 2010 were identified.

Microsurgical and endovascular management of pericallosal aneurysms.

Background: Pericallosal, or A2 bifurcation, aneurysms are an infrequently encountered cause of subarachnoid hemorrhage (SAH). While the International Subarachnoid Aneurysm Trial showed improved outcomes for patients with any ruptured anterior circulation aneurysm treated with embolization, there was also a higher recurrence rate for embolized aneurysms. Notably, there were relatively few pericallosal aneurysms.

Balloon-augmented carotid artery sacrifice with Onyx: a proof of concept study in a swine model.

Introduction: Carotid sacrifice remains a valuable tool in the treatment of select vascular lesions. Neurointerventionalists have relied on coil embolization as their primary means of carotid sacrifice, a procedure that can be lengthy and expensive with long fluoroscopy times. We investigated a novel technique for carotid sacrifice in a swine model using temporary balloon occlusion to achieve proximal flow arrest in the carotid artery while embolizing the vessel with a liquid embolic agent.

Experience with coil embolization of previously clipped aneurysms presenting with rupture.

Introduction: Endovascular coil embolization has an established role alongside microsurgical clipping in the treatment of aneurysms. We studied previously clipped aneurysms that presented as subarachnoid hemorrhage and were treated by coil embolization.

Methods: A retrospective review was performed of two prospectively maintained databases from two institutions (Cleveland Clinic, Emory University) that spanned 12 years.

Evolution of a multidisciplinary cerebrovascular center: lessons learned.

The Cerebrovascular Center at the Cleveland Clinic is an integrated, multidisciplinary center comprising vascular neurologists, neurointensivists, physiatrists, open and endovascular neurosurgeons, interventional neurologists and interventional neuroradiologists administered through a single financial center with unified governance and leadership. This report describes the history and evolution of the center from conceptualization to the present, as well as outlining lessons learned in the formation and maturation of the group.

ε-Aminocaproic acid in angiographically negative subarachnoid hemorrhage patients is safe: a retrospective review of 83 consecutive patients.

Background: ε-Aminocaproic acid (EACA) has been used to reduce the rate of cerebral aneurysm rerupture before definitive treatment. In centers administering EACA to patients with a subarachnoid hemorrhage (SAH), patients eventually diagnosed with angiographically negative subarachnoid hemorrhage (ANSAH) may also initially receive EACA, perhaps placing them at increased risk for ischemic complications.

Objective: To evaluate the effect of short-term EACA on outcomes and secondary measures in patients with ANSAH.

Heading in soccer: dangerous play?

Soccer is the world's most popular sport and unique in that players use their unprotected heads to intentionally deflect, stop, or redirect the ball for both offensive and defensive strategies. Headed balls travel at high velocity pre- and postimpact. Players, coaches, parents, and physicians are justifiably concerned with soccer heading injury risk.

Neurosurgical considerations after bull goring during festivities in Spain and Latin America.

Bullfighting is a highly popular activity during festivities in Spain and Latin America. A scientific society for bullfight injuries, Congreso Internacional de Cirugía Taurina, was founded on November 24, 1974, in recognition of the distinctive pattern of injury that results from bull goring, and a subspecialty of general surgical trauma with emphasis on the acute surgical management of bull-goring injuries has emerged. Injuries to the head and neck are less frequent than genitourinary, inguinal, and abdominal injuries, but are more severe and more likely to result in death.

Brain monitoring after subarachnoid hemorrhage: lessons learned.

Aneurysmal subarachnoid hemorrhage is a serious condition with a high morbidity and mortality rate despite advances in neurocritical care. Intraparenchymal monitors providing continuous bedside physiological data have been introduced into the care of the neurocritically ill and are the focus of clinical research. We review the available technology for bedside brain monitoring and the knowledge that has been gathered and its clinical utility by organizing it into 3 main areas: detecting vasospasm early, establishing end points to resuscitation in the management of cerebral vasospasm, and developing insights into the pathophysiology of the disease.

Difficulties with the neurological assessment of humans following a chimpanzee attack.

Chimpanzee attacks can be vicious, mutilating, and disabling if not fatal. Stereotypically, the hands and face are targeted, and in male victims, genitalia are mutilated. The authors present a case highlighting the difficulties with early neurological assessment following such an attack.

Mid-term results of endovascular coiling of wide-necked aneurysms using double stents in a Y configuration.

Background: Double stenting in a Y configuration may be used to treat a subset of wide-necked aneurysms not amenable to reconstruction with a single stent.

Objective: We studied the feasibility, safety, and mid-term angiographic outcome of patients treated using this technique.

Methods: A retrospective review was undertaken of all coil embolizations of wide-necked aneurysms using double stents in a Y configuration.

The versatile distal access catheter: the Cleveland Clinic experience.

Background: Vascular access is fundamental to any endovascular intervention. Concentric Medical has developed the Outreach Distal Access Catheter (DAC), which affords stable access at the target vessel modulating the forces at play within the thrombectomy device complex. The DAC is a device with novel access characteristics useful in a host of other types of clinical scenarios.

An analysis of inflation times during balloon-assisted aneurysm coil embolization and ischemic complications.

Background And Purpose: The introduction of balloon remodeling has revolutionized the approach to coiling of wide-neck aneurysms. We studied the effects of balloon inflation during coil embolization on ischemic complications.

Methods: A retrospective review was undertaken of the most recent 147 patients undergoing balloon remodeling for unruptured intracranial aneurysm coil embolization at a single institution (81 balloon, 66 unassisted).

Great hospitals of North America: Cleveland Clinic Neurological Surgery.

The Cleveland Clinic Department of Neurological Surgery is highly specialized and integrated with other disciplines in a patient- and disease-centric manner. In order to understand the current state of the Department within the context of the Cleveland Clinic and its international reach, an appreciation of the foundation upon which it stands is critical. We review its history from inception to current state and highlight the notable figures that have influenced the department and residency training program over the years.

Endovascular therapy of very small aneurysms of the anterior communicating artery: five-fold increased incidence of rupture.

Background: Intraprocedural rupture is a dangerous complication of endovascular treatment. Small ruptured anterior communicating artery (ACoA) aneurysms and microaneurysms present a challenge for both surgical and endovascular therapies to achieve obliteration. An understanding of the complication rates of treating ruptured ACoA microaneurysms may help guide therapeutic options.

Antithrombotic states and outcomes in patients with angiographically negative subarachnoid hemorrhage.

Background: Antithrombotic states are encountered frequently, either because of medical therapy or by preexistent pathological states, and may affect the severity of hemorrhagic strokes such as angiographically negative subarachnoid hemorrhages.

Objective: To determine the effects of antithrombotic states on the outcomes of patients with angiographically negative subarachnoid hemorrhage by examining data pooled from 2 institutions.

Methods: This is a retrospective review of patients who experienced angiographically negative subarachnoid hemorrhage at 2 institutions over the past 5 years.

Combined surgical and endovascular approach to a complex dural arteriovenous fistula involving the superior sagittal sinus and torcula.

A complex dural arteriovenous fistula (dAVF) may require complex treatment strategies to achieve successful obliteration. We describe a combined open surgical and endovascular approach to a dAVF involving the superior sagittal sinus (SS) and torcula. A 68-year-old male with Factor V Leiden mutation presented with altered mental status from venous hypertension secondary to a complex, high-flow Borden III dAVF with internal carotid and bilateral external carotid artery feeders draining into the SS and torcula.

Brain tissue oxygen-directed management and outcome in patients with severe traumatic brain injury.

Object: The object of this study was to determine whether brain tissue oxygen (PbtO(2))-based therapy or intracranial pressure (ICP)/cerebral perfusion pressure (CPP)-based therapy is associated with improved patient outcome after severe traumatic brain injury (TBI).

Methods: Seventy patients with severe TBI (postresuscitation GCS score < or = 8), admitted to a neurosurgical intensive care unit at a university-based Level I trauma center and tertiary care hospital and managed with an ICP and PbtO(2) monitor (mean age 40 +/- 19 years [SD]) were compared with 53 historical controls who received only an ICP monitor (mean age 43 +/- 18 years). Therapy for both patient groups was aimed to maintain ICP < 20 mm Hg and CPP > 60 mm Hg.

Methods of scalp revision for deep brain stimulator hardware: case report.

Objective: The use of deep brain stimulation (DBS) to treat a variety of disorders has expanded and will result in an increasingly larger number of patients and implanted electrodes. Hardware failure can result from malfunction, lead migration, fracture, and infection. Scalp erosion with exposure of underlying hardware can lead to potential infectious complications and is, in itself, a strong indication for explantation of the neurostimulation system.

Brain hyperthermia after traumatic brain injury does not reduce brain oxygen.

Objective: Hyperthermia can exacerbate outcome after traumatic brain injury (TBI). In this study, we examined the relationship between brain temperature (BT) and core body temperature and the relationship between BT and brain tissue oxygen (BtO2) to determine whether hyperthermia adversely affects BtO2.

Methods: Seventy-two patients (mean age, 41 +/- 19 years) admitted to a Level I trauma center after TBI were retrospectively identified from a prospective observational database.

Conventional neurocritical care and cerebral oxygenation after traumatic brain injury.

Object: Control of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is the foundation of traumatic brain injury (TBI) management. In this study, the authors examined whether conventional ICP- and CPP-guided neurocritical care ensures adequate brain tissue O2 in the first 6 hours after resuscitation.

Methods: Resuscitated patients with severe TBI (Glasgow Coma Scale score < or = 8 and Injury Severity Scale score > or = 16) who were admitted to a Level I trauma center and who underwent brain tissue O2 monitoring within 6 hours of injury were evaluated as part of a prospective observational database.