Delayed Iatrogenic Direct Carotid Cavernous Fistula Following Flow Diversion for Aneurysm With Spontaneous Healing: A Case Report.

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.

The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device.

OBJECTIVEThromboembolic complications continue to be encountered with Pipeline embolization devices (PEDs) despite routine clopidogrel/aspirin antiplatelet therapy. This study examined the safety and efficacy of prasugrel in the management of clopidogrel-resistant patients treated for cerebral aneurysms.METHODSFour hundred thirty-seven consecutive patients were identified between January 2011 and May 2016.

Submaximal angioplasty for symptomatic intracranial atherosclerosis: a prospective Phase I study.

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.

Hyperacute Carotid Stent Thrombosis During Emergent Revascularization Treated with Intraarterial Eptifibatide After Systemic Administration of Recombinant Tissue Plasminogen Activator.

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.

Combined use of covered stent and flow diversion to seal iatrogenic carotid injury with vessel preservation during transsphenoidal endoscopic resection of clival tumor.

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.

Endovascular treatment of carotid stenosis.

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.

Instent restenosis after carotid stenting: treatment using an off-label cardiac scoring balloon.

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.

Tandem symptomatic internal carotid artery and persistent hypoglossal artery stenosis treated by endovascular stenting and flow reversal.

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.

Endovascular treatment of posterior circulation aneurysms.

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.

The Pipeline embolization device for treatment of intracranial aneurysms.

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.

Endovascular advances for extracranial carotid stenosis.

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.

Cerebrovascular neurosurgery in evolution: the endovascular paradigm.

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.

Advances in endovascular approaches to cerebral aneurysms.

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.

Ruptured mycotic cerebral aneurysm development from pseudoocclusion due to septic embolism.

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.

Endovascular treatment of acute ischemic stroke.

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.

Primary stenting for acute ischemic stroke using the Enterprise vascular reconstruction device: early results.

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.

Carotid artery stenting outcomes: do they correlate with antiplatelet response assays?

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.

Tandem symptomatic internal carotid artery and persistent hypoglossal artery stenosis treated by endovascular stenting and flow reversal.

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.

Localization of the Internal Maxillary Artery for Extracranial-to-Intracranial Bypass through the Middle Cranial Fossa: A Cadaveric Study.

The internal maxillary artery (IMAX) is a promising arterial pedicle to function as a donor vessel for extracranial-to-intracranial (EC-IC) bypass procedures. The access to the IMAX through the anterior portion of the middle cranial fossa floor allows a much shorter interposition graft to be used to create a bypass to the ipsilateral middle cerebral artery and prevents a second incision in the neck. One of the challenges of this technique, however, is the difficulty to find the IMAX through an intracranial approach.

Results of endovascular treatment of middle cerebral artery aneurysms after first giving consideration to clipping.

Background: Middle cerebral artery (MCA) aneurysms are among the more challenging aneurysms for endovascular treatment. We report a contemporary 5-year experience with endovascular therapy for MCA aneurysms at a high-volume neurovascular center.

Methods: Review of prospectively maintained intracranial aneurysm database.

Transfemoral endovascular treatment of atherosclerotic stenotic lesions of the left common carotid artery ostium: case series and review of the literature.

Objective: Endovascular treatment of atherosclerotic stenosis of the left common carotid artery ostium (LCCAO) represents a technical challenge. Unlike stenting of other supra-aortic trunk lesions, LCCAO stenting is not able to be performed from a retrograde approach through the brachial artery. Stenting may be performed via a retrograde approach with a carotid artery cut-down or with total endovascular technique via a transfemoral approach.