A Pragmatic Randomized Trial Comparing Surgical Clipping and Endovascular Treatment of Unruptured Intracranial Aneurysms.

Background And Purpose: Surgical clipping and endovascular treatment are commonly used in patients with unruptured intracranial aneurysms. We compared the safety and efficacy of the 2 treatments in a randomized trial.

Materials And Methods: Clipping or endovascular treatments were randomly allocated to patients with one or more 3- to 25-mm unruptured intracranial aneurysms judged treatable both ways by participating physicians.

Treatment of wide-necked bifurcation aneurysms with the eCLIPs device: 5-year experience of a single center.

Background: The endovascular clip system (eCLIPs) is a novel device with both neck bridging and flow-diversion properties that make it suitable for the treatment of wide-necked bifurcation aneurysms.

Objective: To describe the clinical and radiologic outcomes of the eCLIPs device, including the first-in-man use of the latest version of the device.

Methods: This is a retrospective case series on all the wide-necked bifurcation aneurysms treated with the eCLIPs device in our center.

The Utility of Superselective Rotational Angiography for Frameless Stereotactic Navigation During Craniotomy for Micro-Arteriovenous Malformation.

Background: Micro-arteriovenous malformations (AVMs) can present challenges to neurosurgeons with respect to localization during resection. We sought to describe a novel method that merges super-selective 3-dimensional angiographic images with magnetic resonance imaging (MRI) sequences to facilitate frameless stereotaxic navigation during AVM surgery.

Methods: A retrospective analysis was performed comprising cases that employed merging of angiographic and MRI images for navigation purposes.

Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison.

Objective: There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials.

Reliability of the Diagnosis of Cerebral Vasospasm Using Catheter Cerebral Angiography: A Systematic Review and Inter- and Intraobserver Study.

Background And Purpose: Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the following: 1) to systematically review the literature on the reliability of the diagnosis of cerebral vasospasm using conventional angiography, and 2) to perform an agreement study among clinicians who perform endovascular treatment.

Materials And Methods: Articles reporting a classification system on the degree of cerebral vasospasm on conventional angiography were systematically searched, and agreement studies were identified.

A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: Interim results from ISAT2.

Background And Purpose: Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined.

Methods: The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included.

Surgical or endovascular management of ruptured intracranial aneurysms: an agreement study.

Objective: Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA.

Methods: The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed.

Endovascular Revascularization of a Symptomatic Common Carotid Artery Occlusion.

Although the common carotid artery is the second most common site for extracranial carotid artery stenosis, complete symptomatic occlusion in the absence of devastating stroke is rare. We present a case of complete common carotid artery occlusion failing medical management and requiring endovascular intervention. The clinical presentation, diagnostic investigations, and management of complete carotid artery occlusions are discussed.

Magnetic resonance imaging artifact following anterior cervical discectomy and fusion with a trabecular metal cage.

Object: This study was undertaken to evaluate the impact of postoperative MRI artifact on the assessment of ongoing spinal cord or nerve root compression after anterior cervical discectomy and fusion (ACDF) using a trabecular tantalum cage or bone autograft or allograft.

Methods: The authors conducted a retrospective review of postoperative MRI studies of patients treated surgically for cervical disc degenerative disease or cervical instability secondary to trauma. Standard ACDF with either a trabecular tantalum cage or interbody bone graft had been performed.

Successful use of Solitaire FR for stroke in a pediatric ventricular assist device patient.

Acute ischemic stroke (AIS) remains a devastating and relatively common complication after pediatric ventricular assist device (VAD) placement, with a reported incidence of 29%. We describe an 8-year-old cardiomyopathy patient who had received a HeartWare device, complicated by AIS, and successful treatment with a Solitaire FR device with complete recanalization. This is the first report of the use of this device in a VAD patient and the first reported use in a pediatric patient with middle cerebral artery AIS.

Delayed spontaneous rupture of a posterior inferior cerebellar artery aneurysm following treatment with flow diversion: a clinicopathologic study.

In this report, we present the fatal spontaneous delayed rupture of a previously unruptured large PICA aneurysm following treatment with the PED. Pathology at postmortem examination has supported the theory that intra-aneurysmal thrombus may acutely destabilize the aneurysm wall. Aneurysms with an anatomic arrangement that promote continued flow into the neck may not be optimal candidates for the flow-diversion treatment strategy.

Portal vein embolization with radiolabeled polyvinyl alcohol particles in a swine model: hepatic distribution and implications for pancreatic islet cell transplantation.

The distribution of radiolabeled polyvinyl alcohol microspheres (PVAMs) when infused into the portal vein of domestic swine was investigated, with the purpose of assessing implications for pancreatic islet cell transplantation. PVAMs measuring 100-300 microm (Contour SE) and labeled with (99m)Tc were infused into the main portal vein of 12 swine, with intermittent portal venous pressure measurements. The infusion catheter was introduced antegradely via direct or indirect cannulation of the portal vein.

Endovascular management of an embedded intracranial knife.

Background: Endovascular therapy (ET) is infrequently used in the setting of acute penetrating intracranial trauma.

Methods: We report a case where ET was used immediately prior to and following removal of an embedded intracranial knife, which was found to be disrupting the anterior cerebral artery.

Results: The proximal vessel was coiled and angiographically occluded and then the knife was removed with the microcatheter in place.

Photodynamic therapy of the canine prostate: intra-arterial drug delivery.

Purpose: Interstitial photodynamic therapy (PDT) selectively destroys tissue targeted with a photosensitizer and then exposed to light of a specific wavelength. We report a novel delivery method--intra-arterial drug delivery for PDT of the prostate--in a canine model.

Methods: To evaluate drug distribution, the prostatovesical artery was selectively cannulated and photosensitizers alone or in conjunction with 99m-technetium-labeled macro-aggregated albumin ((99m)Tc-MAA) were injected via a 3 Fr microcatheter in 8 animals.

A pilot study of magnetic resonance imaging-guided closed reduction of cervical spine fractures.

Study Design: We report on a prospective selective case series of 17 patients with cervical fracture-dislocations treated with closed reduction under MRI guidance.

Objective: To demonstrate the safe and effective use of in-line axial traction in the reduction of cervical fracture-dislocations using MRI guidance.

Summary Of Background Data: Closed reduction of the cervical spine for acute fracture-dislocations has been a traditional technique used for restoring vertebral alignment and providing neural element decompression.

"Malignant" carotid artery dissection.

Purpose: Carotid artery dissection resulting in occlusion or severe narrowing and massive intracranial embolism can result in life-threatening hemispheric ischemia. Aggressive endovascular and microsurgical measures may be necessary to salvage life and minimize stroke morbidity in this extreme situation.

Patients And Methods: We have treated two middle-aged women who presented within an hour of spontaneous cervical internal carotid artery (ICA) dissection causing hemiplegia, forced head and eye deviation, and declining consciousness.

CT angiography for the detection and characterization of carotid artery bifurcation disease.

Background And Purpose: Computed tomographic angiography (CTA) is a relatively new and minimally invasive method of imaging intracranial and extracranial blood vessels. The main purpose of this study was to compare CTA to the current gold standard of arterial imaging, digital subtraction angiography (DSA), for the detection and quantification of carotid artery bifurcation stenosis. We also compared Doppler ultrasound (US) with these 2 techniques.

CT angiography for the detection of cerebral vasospasm in patients with acute subarachnoid hemorrhage.

Background And Purpose: Digital subtraction angiography (DSA) is the standard of reference for detecting cerebral vasospasm after subarachnoid hemorrhage (SAH). CT angiography (CTA) is a relatively recent method for depicting the intracranial arterial vasculature. The purpose of this study was to compare CTA and DSA in the detection and quantification of cerebral vasospasm.

Computed tomographic angiography versus digital subtraction angiography for the diagnosis and early treatment of ruptured intracranial aneurysms.

Objective: Computed tomographic angiography (CTA) is a rapid and minimally invasive method of detecting intracranial aneurysms. We wished to determine whether CTA could replace digital subtraction angiography (DSA) in the diagnosis and operative planning of ruptured cerebral aneurysms.

Methods: In a prospective study, patients with subarachnoid hemorrhage diagnosed by plain computed tomography underwent CTA, DSA, or both.

Mastoid pneumocele causing atlantooccipital pneumatization.

A 49-year-old woman had a palpable mass in her occipital region. Plain radiographs and CT examination revealed extensive atlantooccipital pneumatization with findings consistent with the diagnosis of mastoid pneumocele. Decompression was achieved with placement of a myringotomy tube, resulting in prompt symptomatic relief.

Experience with computed tomographic angiography for the detection of intracranial aneurysms in the setting of acute subarachnoid hemorrhage.

Objective: To objectively compare computed tomographic angiography (CTA) with selective digital subtraction angiography (DSA) in the detection and anatomic definition of intracranial aneurysms, particularly in the setting of acute subarachnoid hemorrhage (SAH).

Methods: In a blinded prospective study, 40 patients with known or suspected intracranial saccular aneurysms underwent both CTA and DSA, including 32 consecutive patients with SAH in whom CTA was performed after CT images were obtained diagnostic for SAH. The CT angiograms were interpreted for presence, location, and size of the aneurysms, and anatomic features, such as the number of aneurysms lobes, aneurysm neck size (< or = 4 mm), and the number of adjacent arterial branches were suggested.

Pharmacological and morphological effects of in vitro transluminal balloon angioplasty on normal and vasospastic canine basilar arteries.

Despite growing clinical use of transluminal balloon angioplasty (TBA) to treat cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH), the precise mechanism of action of balloon dilation on the cerebral arterial wall is unknown. In this experiment the authors examined the pharmacological and morphological changes in 10 normal and 12 vasospastic canine basilar arteries following in vitro silicone microballoon TBA. For the SAH group in which the double-hemorrhage model was used, vasospasm was confirmed by angiography and the animals were killed on Day 7 after the first SAH.

MR of deep cerebral venous thrombosis.

Two cases of deep cerebral venous thrombosis are presented with specific reference to the CT and MR findings. The MR findings are discussed, with comparison to the findings of superficial cerebral sino-venous occlusion.