Endovascular management of symptomatic spasm of radial artery bypass graft: technical case report.

Objective: To describe the technique of endovascular access for treatment of vasospasm of a radial artery bypass graft from the occipital artery to the M3 branch of the middle cerebral artery (MCA) in a patient with moyamoya disease.

Clinical Presentation: A 32-year-old woman presented with recurrent right-sided ischemic symptoms in the territory of a previous stroke. Angiographic findings were consistent with moyamoya disease, and a perfusion deficit was identified on computed tomography (CT) perfusion imaging.

External carotid artery stenting to treat patients with symptomatic ipsilateral internal carotid artery occlusion: a multicenter case series.

Background: The external carotid artery (ECA) anastomoses in many distal territories supplied by the internal carotid artery (ICA) and is an important source of collateral circulation to the brain. Stenosis of the ECA in ipsilateral ICA occlusion can produce ischemic sequelae.

Objective: To examine the effectiveness of ECA stenting in treating symptomatic ipsilateral ICA occlusion.

Acute ischemic stroke and infections.

We present an overview of multiple infections in relation to acute ischemic stroke and the therapeutic options available. Conditions that are a direct cause of stroke (infectious endocarditis, meningoencephalitides, and human immunodeficiency virus infection), the pathophysiologic mechanism responsible for stroke, and treatment dilemmas are presented. Independently or in conjunction with conventional risk factors, chronic and acute infections can trigger an acute ischemic stroke through an accelerated process of atherosclerosis and immunohematologic alterations.

Initial experience with an everolimus-eluting, second-generation drug-eluting stent for treatment of intracranial atherosclerosis.

Background And Purpose: High in-stent restenosis (ISR) rates have been reported after treatment of intracranial atherosclerotic stenosis (ICAS). Balloon-mounted drug-eluting stent (DES) implantation has led to an ISR reduction in coronary vessels and may provide a solution to overcome this obstacle in the intracranial circulation. We present our initial experience with the everolimus-eluting stent (EES; Abbott Vascular, Abbott Park, Illinois, USA), a second-generation balloon-mounted DES, for ICAS treatment.

Primary intracranial stenting in acute ischemic stroke.

Acute intracranial stroke is a major source of morbidity and mortality in the United States. Recent studies have shown improved clinical outcomes for patients who achieve timely arterial recanalization. Multimodal therapies have evolved to meet this end point and include intravenous and/or intra-arterial thrombolysis and mechanical thrombolysis.

Neurointerventional procedures for unruptured intracranial aneurysms under procedural sedation and local anesthesia: a large-volume, single-center experience.

Object: In this paper, the authors' goal was to report the outcome of patients with unruptured intracranial aneurysms undergoing endovascular treatment under conscious sedation (local anesthesia).

Methods: Between November 5, 2001, and February 5, 2009, the authors treated 340 patients with 358 unruptured aneurysms by using neurointerventional procedures at Millard Fillmore Gates Hospital (Buffalo, New York). The data were retrospectively reviewed for periprocedural safety and long-term follow-up.

Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: preliminary results from a retrospective, multicenter study.

Background And Purpose: Patients undergoing intra-arterial therapy (IAT) for acute ischemic stroke receive either general anesthesia (GA) or conscious sedation. GA may delay time to treatment, whereas conscious sedation may result in patient movement and compromise the safety of the procedure. We sought to determine whether there were differences in safety and outcomes in GA patients before initiation of IAT.

Size ratio correlates with intracranial aneurysm rupture status: a prospective study.

Background And Purpose: The prediction of intracranial aneurysm (IA) rupture risk has generated significant controversy. The findings of the International Study of Unruptured Intracranial Aneurysms (ISUIA) that small anterior circulation aneurysms (<7 mm) have a 0% risk of subarachnoid hemorrhage in 5 years is difficult to reconcile with other studies that reported a significant portion of ruptured IAs are small. These discrepancies have led to the search for better aneurysm parameters to predict rupture.

Restenosis rates following vertebral artery origin stenting: does stent type make a difference?

Objectives: To compare our experience with sirolimus and paclitaxel-eluting stents (drug-eluting stents [DES]) and non-drug-eluting stents (NDES) for treatment of vertebral artery (VA) origin stenosis and review the literature.

Methods: A retrospective review of our prospectively collected database was performed. Clinical and radiologic follow up was obtained by reviewing office records and radiology.

Size ratio for clinical assessment of intracranial aneurysm rupture risk.

Objectives: We previously used three-dimensional (3D) volumetric analysis to identify a novel intracranial aneurysm (IA) morphological metric, aneurysm-to-parent vessel size ratio (SR), which strongly correlated with aneurysm rupture. However, complex 3D analysis is not easily obtained, and ubiquitous IA risk assessment is traditionally performed with two-dimensional (2D) imaging, typically with size being the sole considered morphometric. Because only easily applicable 2D measurements will be of clinical value, we sought to investigate the correlation of SR determined from 2D angiography with IA rupture status.

Safety, effectiveness, and practicality of endovascular therapy within the first 3 hours of acute ischemic stroke onset.

Objective: This study assesses the safety, effectiveness, and practicality of endovascular therapy for ischemic stroke within the first 3 hours of symptom onset.

Methods: A retrospective chart review (January 2000-July 2008) was performed of 94 consecutive patients who had endovascular therapy within 3 hours after acute ischemic stroke onset. Endovascular therapy was administered in patients in whom intravenous (IV) thrombolysis failed or was contraindicated.

Use of a vascular reconstruction device to salvage acute ischemic occlusions refractory to traditional endovascular recanalization methods.

Object: Acute revascularization has been associated with improved stroke outcomes. The Prolyse in Acute Cerebral Thromboembolism (PROACT II) trial achieved recanalization rates of 66%. The Multi Mechanical Embolus Removal in Cerebral Ischemia (Multi MERCI) trial achieved recanalization in 70% of patients.

First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (stent-assisted recanalization in acute ischemic stroke).

Background And Purpose: Acute revascularization is associated with improved outcomes in ischemic stroke patients. However, it is unclear which method of intraarterial intervention, if any, is ideal. Numerous case series and cardiac literature parallels suggest that acute stenting may yield high revascularization levels with low associated morbidity.

Safety and effectiveness of endovascular therapy after 8 hours of acute ischemic stroke onset and wake-up strokes.

Background And Purpose: This is a retrospective review of patients who underwent endovascular recanalization > or = 8 hours after acute ischemic stroke symptom onset, including wake-up strokes, between June 2005 and June 2008.

Methods: Thirty patients with a premorbid modified Rankin score < or = 1 and NIHSS between 5 and 22 were included. All had admission CT, CTA, and CT perfusion scans to evaluate for salvageable brain tissue.

Defining the risk of retreatment for aneurysm recurrence or residual after initial treatment by endovascular coiling: a multicenter study.

Objective: Endovascular treatment of intracranial aneurysms is less invasive than surgical repair but poses a higher risk for aneurysm recurrence, which may necessitate retreatment, thus adding to the long-term risk. Cerebrovascular neurosurgeons from 8 institutions in the United States and Puerto Rico collaborated to assess the risk of retreatment for residual or recurrent aneurysms after the initial endovascular coiling.

Methods: Data were prospectively recorded for 311 patients with coiled intracranial aneurysms who underwent 352 retreatment procedures after angiographic or clinical recurrence (hemorrhage after initial coiling).

Molecular alterations associated with aneurysmal remodeling are localized in the high hemodynamic stress region of a created carotid bifurcation.

Objective: Although elevated hemodynamics has been speculated to play a key role in intracranial aneurysm (IA) initiation, little is known about the specific hemodynamic microenvironment that triggers aneurysmal vascular degradation. We previously demonstrated maladaptive remodeling characteristic of IA initiation occurring in hemodynamic regions of combined high wall shear stress (WSS) and high WSS gradient near the apex of an experimentally created carotid bifurcation. This study examines whether this remodeling recapitulates the molecular changes found in IAs and whether molecular changes also correspond to specific hemodynamic environments.

Pharos neurovascular intracranial stent: elective use for a symptomatic stenosis refractory to medical therapy.

The Warfarin-Aspirin Symptomatic Intracranial Disease study investigators demonstrated that medically managed patients with symptomatic intracranial stenosis experience a 7-11% annual stroke risk. Early treatment efforts utilized balloon-mounted coronary stents, which provided excellent angiographic results (postprocedure stenoses <10%), versus percutaneous transluminal angioplasty (PTA) alone (40%). However, the rigidity of balloon-mounted coronary stents provided limited access to the tortuous cerebrovasculature.

Influence of intracranial aneurysm-to-parent vessel size ratio on hemodynamics and implication for rupture: results from a virtual experimental study.

Objective: The effectiveness of intracranial aneurysm (IA) size as a predictor for rupture has been debated. We recently performed a retrospective analysis of IA morphology and found that a new index, namely, aneurysm-to-parent vessel size ratio (SR), was strongly correlated with IA rupture, with 77% of ruptured IAs showing an SR of more than 2, and 83% of unruptured IAs showing an SR of 2 or less. As hemodynamics have been implicated in both IA development and rupture, we examine how varying SR influences intra-aneurysmal hemodynamics.

Inadvertent subclavian artery catheter placement complicated by stroke: endovascular management and review.

Background: Removal of large-bore venous catheters misplaced within the subclavian artery risks significant hemorrhage due to the noncompressible entry site. Comorbidities in these patients often make traditional surgical approaches prohibitive.

Case Description: We present a case of inadvertent subclavian artery placement of a central venous catheter complicated by thromboembolic stroke, illustrate treatment with a combination of percutaneous closure and temporary balloon tamponade, and review the endovascular management of this unusual problem.

The asymmetric vascular stent: efficacy in a rabbit aneurysm model.

Background And Purpose: Development of hemodynamic modifying devices to treat intracranial aneurysms is an active area of research. The asymmetrical vascular stent (AVS), a stent containing a low-porosity patch, is such device. We evaluate AVS efficacy in an in vivo intracranial aneurysm model.

Retrograde angioplasty for basilar artery stenosis: bypassing bilateral vertebral artery occlusions.

Basilar artery angioplasty with or without stenting is an emerging and promising treatment for vertebrobasilar insufficiency that is refractory to medical therapy. The usual approach is via a transfemoral route, with access directly through the vertebral artery (VA). An approach from the anterior circulation via the posterior communicating artery has been reported for optimal stent positioning and deployment across basilar apex aneurysms.

Does angiographic surveillance pose a risk in the management of coiled intracranial aneurysms? A multicenter study of 2243 patients.

Objective: Endovascular treatment of intracranial aneurysms is a less invasive alternative than surgical repair. However, the higher risk of recurrence after coiling necessitates regular angiographic surveillance, which has associated risks. To date, the risk of surveillance angiography has not been quantified in patients with intracranial aneurysms treated by endovascular embolization.

Clinical and angiographic outcome after endovascular management of giant intracranial aneurysms.

Objective: Giant (>or=25 mm) intracranial aneurysms (IA) have an extremely poor natural history and continue to confound modern techniques for management. Currently, there is a dearth of large series examining endovascular treatment of giant IAs only.

Methods: We reviewed long-term clinical and radiological outcome from a series of 39 consecutive giant IAs treated with endovascular repair in 38 patients at 2 tertiary referral centers.